Methods for treating inflammation, autoimmune disorders and pain

ABSTRACT

Disclosed herein are methods of treating, reducing, or preventing a disease such as oral mucositis, gastric mucositis, or inflammatory fibrosis, comprising identifying a patient in need of treatment and administering a therapeutically effective amount of at least one cationic steroid antimicrobial (CSA), or a pharmaceutically acceptable salt thereof. Kits comprising such compositions and instructions on such methods are also contemplated herein.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation in part of U.S. patent applicationSer. No. 14/208,082, filed Mar. 13, 2014, which claims the benefit ofU.S. Provisional Patent Application Ser. No. 61/794,721, filed Mar. 15,2013. This application also claims the benefit of U.S. ProvisionalPatent Application Ser. No. 61/892,263, filed Oct. 17, 2013. Thedisclosures of the foregoing applications are incorporated herein intheir entirety.

BACKGROUND

1. Field

Cationic steroidal antimicrobials (“CSAs”) for treating certain diseasesand symptoms such as oral mucositis, gingivitis, periodontitis, gastricmucositis, inflammatory fibrosis, gastritis, colitis, ileitis, Crohn'sdisease, chronic inflammatory intestinal disease, inflammatory bowelsyndrome, chronic inflammatory bowel disease, celiac disease, ulcerativecolitis, a gastric ulcer, a peptic ulcer, a buccal ulcer, anasopharyngeal ulcer, an esophageal ulcer, a duodenal ulcer, agastrointestinal ulcer, an autoimmune disorder, and/or pain.

2. Description of the Related Art

Inflammation is a biological response to harmful stimuli, such aspathogens, damaged cells, or irritants. As such, inflammation is a majorcomponent of the nonspecific defense system. The classical signs ofacute inflammation are pain (dolor), heat (calor), redness (rubor),swelling (tumor), and loss of function. Although infection is caused bya microorganism, inflammation is one of the responses by the infectedsubject to the pathogen.

Inflammation can be classified as either acute or chronic. Acuteinflammation is the initial response of the body to harmful stimuli andis achieved by the increased movement of plasma and leukocytes(especially granulocytes) from the blood into the injured tissues. Acascade of biochemical events propagates and matures the inflammatoryresponse, involving the local vascular system, the immune system, andvarious cells within the injured tissue. Prolonged inflammation, knownas chronic inflammation, leads to a progressive shift in the type ofcells present at the site of inflammation and is characterized bysimultaneous destruction and healing of the tissue from the inflammatoryprocess

Progressive destruction of the tissue would compromise the survival ofthe organism. However, chronic inflammation can also lead to a host ofdiseases, such as hay fever, periodontitis, atherosclerosis, rheumatoidarthritis, and even cancer (e.g., gallbladder carcinoma). It is for thatreason that inflammation is normally closely regulated by the body.

Periodontal disease, such as oral mucositis, gingivitis andperiodontitis, is one of the most common diseases and its severe form isestimated to afflict 10% of the population of the United States.Bacterial invasion plays an essential role in periodontal disease.Bacteria also trigger the host tissue to express an immunoinflammatoryresponse, and this process can lead to resorption of the alveolar bone,connective tissue loss, the formation of periodontal pockets, andeventually loss of teeth. Other diseases are characterized by a host'sinflammatory response. Such diseases include, but are not limited togastric mucositis, inflammatory fibrosis, gastritis, colitis, ileitis,Crohn's disease, chronic inflammatory intestinal disease, inflammatorybowel syndrome, chronic inflammatory bowel disease, cystic fibrosis,celiac disease, ulcerative colitis, gastric ulcers, peptic ulcers,buccal ulcers, nasopharyngeal ulcers, esophageal ulcers, duodenalulcers, and gastrointestinal ulcers. Therefore, a need exists to developnew methods for treating such diseases.

Many, but not all, disorders responsible for an inflammatory responseimplicate autoimmune disorders. An autoimmune disorder is a conditionthat occurs when the immune system mistakenly attacks and destroyshealthy body tissue. In patients with an autoimmune disorder, the immunesystem can't tell the difference between healthy body tissue andantigens. The result is an immune response that destroys normal bodytissues. What causes the immune system to no longer tell the differencebetween healthy body tissues and antigens is unknown. One theory is thatsome microorganisms (such as bacteria or viruses) or drugs may triggersome of these changes, especially in people who have genes that makethem more likely to get autoimmune disorders. Regardless, new treatmentsare needed to help patients suffering from such diseases.

As previously mentioned, pain is often a sign of acute inflammation (butnot all pain is caused by inflammation). Pain may be divided into twogeneral categories—acute and chronic. Acute pain is typicallycharacterized by rapid its onset, intensity, and short duration. Chronicpain, however, tends to be persistent, such as pain associated withinflammation, arthritis, etc. Chronic pain may also cause individuals toexhibit enhanced sensitivity to painful stimulus (hyperalgesia); painfulsensation to normally non-painful stimulus (allodynia); burningsensation; and unusual nociceptive descriptors (stabbing, sharp,throbbing, etc.). In addition, chronic pain may also have additionalphysiological consequences such as trigger point producing pain(myofascial pain or radicular pain) or sympathetic dystrophy (warm/coldextremities, joint stiffness, or bone demineralization). Althoughvarious methods and substances for treating pain exist, such methods areoften an inconvenience or the substances impair the patient's motorfunctions and/or can lead to addiction. Moreover, many of the treatmentsfor acute pain may be addictive and are, therefore, not appropriate forlong term use. Thus, new pain treatments and substances are needed.

SUMMARY

Some embodiments describe a method of treating, reducing, or preventinga disease or symptom selected from oral mucositis, gingivitis,periodontitis, gastric mucositis, inflammatory fibrosis, gastritis,colitis, ileitis, Crohn's disease, chronic inflammatory intestinaldisease, inflammatory bowel syndrome, chronic inflammatory boweldisease, celiac disease, ulcerative colitis, a gastric ulcer, a pepticulcer, a buccal ulcer, a nasopharyngeal ulcer, an esophageal ulcer, aduodenal ulcer, a gastrointestinal ulcer, an autoimmune disorder, orpain, comprising: identifying a patient in need of treating, reducing,or preventing a disease or symptom selected from oral mucositis,gingivitis, periodontitis, gastric mucositis, gastritis, colitis,ileitis, Crohn's disease, chronic inflammatory intestinal disease,inflammatory bowel syndrome, chronic inflammatory bowel disease, cysticfibrosis, celiac disease, ulcerative colitis, a gastric ulcer, a pepticulcer, a buccal ulcer, a nasopharyngeal ulcer, an esophageal ulcer, aduodenal ulcer, a gastrointestinal ulcer, an autoimmune disorder, orpain; and administering a therapeutically effective amount of at leastone cationic steroidal antimicrobial (CSA), or a pharmaceuticallyacceptable sat thereof.

In some embodiments, the CSA is a compound of Formula (I) or apharmaceutically acceptable salt thereof:

wherein rings A, B, C, and D are independently saturated, or are fullyor partially unsaturated, provided that at least two of rings A, B, C,and D are saturated; m, n, p, and q are independently 0 or 1; R₁ throughR₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, and R₁₈ are independently selected fromthe group consisting of hydrogen, hydroxyl, a substituted orunsubstituted alkyl, a substituted or unsubstituted hydroxyalkyl, asubstituted or unsubstituted alkyloxyalkyl, a substituted orunsubstituted alkylcarboxyalkyl, a substituted or unsubstitutedalkylaminoalkyl, a substituted or unsubstituted alkylaminoalkylamino, asubstituted or unsubstituted alkylaminoalkylaminoalkylamino, asubstituted or unsubstituted aminoalkyl, a substituted or unsubstitutedaryl, a substituted or unsubstituted arylaminoalkyl, a substituted orunsubstituted haloalkyl, a substituted or unsubstituted alkenyl, asubstituted or unsubstituted alkynyl, oxo, a linking group attached to asecond steroid molecule, a substituted or unsubstituted aminoalkyloxy, asubstituted or unsubstituted aminoalkyloxyalkyl, a substituted orunsubstituted aminoalkylcarboxy, a substituted or unsubstitutedaminoalkylaminocarbonyl, a substituted or unsubstitutedaminoalkylcarboxamido, a substituted or unsubstituteddi(alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—, H₂N—HC(Q₅)-C(O)—N(H)—, asubstituted or unsubstituted azidoalkyloxy, a substituted orunsubstituted cyanoalkyloxy, P.G.-HN—HC(Q₅)-C(O)—O—, a substituted orunsubstituted guanidinoalkyloxy, a substituted or unsubstitutedquaternaryammoniumalkylcarboxy, and a substituted or unsubstitutedguanidinoalkyl carboxy, where Q₅ is a side chain of any amino acid(including a side chain of glycine, i.e., H), and P.G. is an aminoprotecting group; and R₅, R₈, R₉, R₁₀, R₁₃, R₁₄ and R₁₇ areindependently deleted when one of rings A, B, C, or D is unsaturated soas to complete the valency of the carbon atom at that site, or R₅, R₈,R₉, R₁₀, R₁₃, and R₁₄ are independently selected from the groupconsisting of hydrogen, hydroxyl, a substituted or unsubstituted alkyl,a substituted or unsubstituted hydroxyalkyl, a substituted orunsubstituted alkyloxyalkyl, a substituted or unsubstituted aminoalkyl,a substituted or unsubstituted aryl, a substituted or unsubstitutedhaloalkyl, a substituted or unsubstituted alkenyl, a substituted orunsubstituted alkynyl, oxo, a linking group attached to a secondsteroid, a substituted or unsubstituted aminoalkyloxy, a substituted orunsubstituted aminoalkylcarboxy, a substituted or unsubstitutedaminoalkylaminocarbonyl, a substituted or unsubstituteddi(alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—, H₂N—HC(Q₅)-C(O)—N(H)—,azidoalkyloxy, cyanoalkyloxy, P.G.-HN—HC(Q₅)-C(O)—O—, guanidinoalkyloxy,and guanidinoalkylcarboxy, where Q₅ is a side chain of any amino acid,P.G. is an amino protecting group, provided that at least two or threeof R₁₋₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, R₁₇, and R₁₈ are independentlyselected from the group consisting of a substituted or unsubstitutedaminoalkyl, a substituted or unsubstituted aminoalkyloxy, a substitutedor unsubstituted alkylcarboxyalkyl, a substituted or unsubstitutedalkylaminoalkylamino, a substituted or unsubstitutedalkylaminoalkylaminoalkylamino, a substituted or unsubstitutedaminoalkylcarboxy, a substituted or unsubstituted arylaminoalkyl, asubstituted or unsubstituted aminoalkyloxyaminoalkylaminocarbonyl, asubstituted or unsubstituted aminoalkylaminocarbonyl, a substituted orunsubstituted aminoalkylcarboxyamido, a quaternaryammoniumalkylcarboxy,a substituted or unsubstituted di(alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—,H₂N—HC(Q₅)-C(O)—N(H)—, azidoalkyloxy, cyanoalkyloxy,P.G.-HN—HC(Q₅)-C(O)—O—, a substituted or unsubstitutedguanidinoalkyloxy, and a substituted or unsubstitutedguanidinoalkylcarboxy.

In some embodiments, R₁ through R₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, and R₁₈are independently selected from the group consisting of hydrogen,hydroxyl, a substituted or unsubstituted (C₁-C₁₈) alkyl, a substitutedor unsubstituted (C₁-C₁₈) hydroxyalkyl, a substituted or unsubstituted(C₁-C₁₈) alkyloxy-(C₁-C₁₈) alkyl, a substituted or unsubstituted(C₁-C₁₈) alkylcarboxy-(C₁-C₁₈) alkyl, a substituted or unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈)alkyl, a substituted or unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, a substituted or unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, asubstituted or unsubstituted (C₁-C₁₈) aminoalkyl, a substituted orunsubstituted aryl, a substituted or unsubstituted arylamino-(C₁-C₁₈)alkyl, a substituted or unsubstituted (C₁-C₁₈) haloalkyl, a substitutedor unsubstituted C₂-C₆ alkenyl, a substituted or unsubstituted C₂-C₆alkynyl, oxo, a linking group attached to a second steroid, asubstituted or unsubstituted (C₁-C₁₈) aminoalkyloxy, a substituted orunsubstituted (C₁-C₁₈) aminoalkyloxy-(C₁-C₁₈) alkyl, a substituted orunsubstituted (C₁-C₁₈) aminoalkylcarboxy, a substituted or unsubstituted(C₁-C₁₈) aminoalkylaminocarbonyl, a substituted or unsubstituted(C₁-C₁₈) aminoalkylcarboxamido, a substituted or unsubstituted di(C₁-C₁₈alkyl) aminoalkyl, H₂N—HC(Q₅)-C(O)—O—, H₂N—HC(Q₅)-C(O)—N(H)—, asubstituted or unsubstituted (C₁-C₁₈) azidoalkyloxy, a substituted orunsubstituted (C₁-C₁₈) cyanoalkyloxy, P.G.-HN—HC(Q₅)-C(O)—O—, asubstituted or unsubstituted (C₁-C₁₈) guanidinoalkyloxy, a substitutedor unsubstituted (C₁-C₁₈) quaternaryammoniumalkylcarboxy, and asubstituted or unsubstituted (C₁-C₁₈) guanidinoalkyl carboxy, where Q₅is a side chain of any amino acid (including a side chain of glycine,i.e., H), and P.G. is an amino protecting group; R₅, R₈, R₉, R₁₀, R₁₃,R₁₄ and R₁₇ are independently deleted when one of rings A, B, C, or D isunsaturated so as to complete the valency of the carbon atom at thatsite, or R₅, R₈, R₉, R₁₀, R₁₃, and R₁₄ are independently selected fromthe group consisting of hydrogen, hydroxyl, a substituted orunsubstituted (C₁-C₁₈) alkyl, a substituted or unsubstituted (C₁-C₁₈)hydroxyalkyl, a substituted or unsubstituted (C₁-C₁₈) alkyloxy-(C₁-C₁₈)alkyl, a substituted or unsubstituted (C₁-C₁₈) aminoalkyl, a substitutedor unsubstituted aryl, a substituted or unsubstituted (C₁-C₁₈)haloalkyl, a substituted or unsubstituted (C₂-C₆) alkenyl, a substitutedor unsubstituted (C₂-C₆) alkynyl, oxo, a linking group attached to asecond steroid, a substituted or unsubstituted (C₁-C₁₈) aminoalkyloxy, asubstituted or unsubstituted (C₁-C₁₈) aminoalkylcarboxy, a substitutedor unsubstituted (C₁-C₁₈) aminoalkylaminocarbonyl, a substituted orunsubstituted di(C₁-C₁₈ alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—,H₂N—HC(Q₅)-C(O)—N(H)—, a substituted or unsubstituted (C₁-C₁₈)azidoalkyloxy, a substituted or unsubstituted (C₁-C₁₈) cyanoalkyloxy,P.G.-HN—HC(Q₅)-C(O)—O—, a substituted or unsubstituted (C₁-C₁₈)guanidinoalkyloxy, and (C₁-C₁₈) guanidinoalkylcarboxy, where Q₅ is aside chain of any amino acid, and P.G. is an amino protecting group;provided that at least two or three of R₁₋₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆,R₁₇, and R₁₈ are independently selected from the group consisting of asubstituted or unsubstituted (C₁-C₁₈) aminoalkyl, a substituted orunsubstituted (C₁-C₁₈) aminoalkyloxy, a substituted or unsubstituted(C₁-C₁₈) alkylcarboxy-(C₁-C₁₈) alkyl, a substituted or unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, a substituted or unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino (C₁-C₁₈) alkylamino, asubstituted or unsubstituted (C₁-C₁₈) aminoalkylcarboxy, a substitutedor unsubstituted arylamino (C₁-C₁₈) alkyl, a substituted orunsubstituted (C₁-C₁₈) aminoalkyloxy (C₁-C₁₈) aminoalkylaminocarbonyl, asubstituted or unsubstituted (C₁-C₁₈) aminoalkylaminocarbonyl, asubstituted or unsubstituted (C₁-C₁₈) aminoalkylcarboxyamido, asubstituted or unsubstituted (C₁-C₁₈) quaternaryammoniumalkylcarboxy, asubstituted or unsubstituted di(C₁-C₁₈ alkyl)aminoalkyl,H₂N—HC(Q₅)-C(O)—O—, H₂N—HC(Q₅)-C(O)—N(H)—, a substituted orunsubstituted (C₁-C₁₈) azidoalkyloxy, a substituted or unsubstituted(C₁-C₁₈) cyanoalkyloxy, P.G.-HN—HC(Q₅)-C(O)—O—, a substituted orunsubstituted (C₁-C₁₈) guanidinoalkyloxy, and a substituted orunsubstituted (C₁-C₁₈) guanidinoalkylcarboxy.

In some embodiments, R₁ through R₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, and R₁₈are independently selected from the group consisting of hydrogen,hydroxyl, an unsubstituted (C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈)hydroxyalkyl, unsubstituted (C₁-C₁₈) alkyloxy-(C₁-C₁₈) alkyl,unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈) alkyl, unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino, (C₁-C₁₈) alkylamino-(C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted (C₁-C₁₈) aminoalkyl, anunsubstituted aryl, an unsubstituted arylamino-(C₁-C₁₈) alkyl, oxo, anunsubstituted (C₁-C₁₈) aminoalkyloxy, an unsubstituted (C₁-C₁₈)aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxy, an unsubstituted (C₁-C₁₈) aminoalkylaminocarbonyl, anunsubstituted (C₁-C₁₈) aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈alkyl)aminoalkyl, unsubstituted (C₁-C₁₈) guanidinoalkyloxy,unsubstituted (C₁-C₁₈) quaternaryammoniumalkylcarboxy, and unsubstituted(C₁-C₁₈) guanidinoalkyl carboxy; R₅, R₈, R₉, R₁₀, R₁₃, R₁₄ and R₁₇ areindependently deleted when one of rings A, B, C, or D is unsaturated soas to complete the valency of the carbon atom at that site, or R₅, R₈,R₉, R₁₀, R₁₃, and R₁₄ are independently selected from the groupconsisting of hydrogen, hydroxyl, an unsubstituted (C₁-C₁₈) alkyl,unsubstituted (C₁-C₁₈) hydroxyalkyl, unsubstituted (C₁-C₁₈)alkyloxy-(C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈) alkylamino-(C₁-C₁₈) alkyl, (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted(C₁-C₁₈) aminoalkyl, an unsubstituted aryl, an unsubstitutedarylamino-(C₁-C₁₈) alkyl, oxo, an unsubstituted (C₁-C₁₈) aminoalkyloxy,an unsubstituted (C₁-C₁₈) aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted(C₁-C₁₈) aminoalkylcarboxy, an unsubstituted (C₁-C₁₈)aminoalkylaminocarbonyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈ alkyl)aminoalkyl,unsubstituted (C₁-C₁₈) guanidinoalkyloxy, unsubstituted (C₁-C₁₈)quaternaryammoniumalkylcarboxy, and unsubstituted (C₁-C₁₈)guanidinoalkyl carboxy; provided that at least two or three of R₁₋₄, R₆,R₇, R₁₁, R₁₂, R₁₅, R₁₆, R₁₇, and R₁₈ are independently selected from thegroup consisting of hydrogen, hydroxyl, an unsubstituted (C₁-C₁₈) alkyl,unsubstituted (C₁-C₁₈) hydroxyalkyl, unsubstituted (C₁-C₁₈)alkyloxy-(C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈) alkylamino-(C₁-C₁₈) alkyl, unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted(C₁-C₁₈) aminoalkyl, an unsubstituted aryl, an unsubstitutedarylamino-(C₁-C₁₈) alkyl, oxo, an unsubstituted (C₁-C₁₈) aminoalkyloxy,an unsubstituted (C₁-C₁₈) aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted(C₁-C₁₈) aminoalkylcarboxy, an unsubstituted (C₁-C₁₈)aminoalkylaminocarbonyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈ alkyl)aminoalkyl,unsubstituted (C₁-C₁₈) guanidinoalkyloxy, unsubstituted (C₁-C₁₈)quaternaryammoniumalkylcarboxy, and unsubstituted (C₁-C₁₈)guanidinoalkyl carboxy.

In some embodiments, the CSA, or a pharmaceutically acceptable saltthereof, is selected from the compound of Formula (II):

In some embodiments, rings A, B, C, and D are independently saturated.

In some embodiments, R₃, R₇, R₁₂, and R₁₈ are independently selectedfrom the group consisting of hydrogen, an unsubstituted (C₁-C₁₈) alkyl,unsubstituted (C₁-C₁₈) hydroxyalkyl, unsubstituted (C₁-C₁₈)alkyloxy-(C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈) alkylamino-(C₁-C₁₈)alkyl, unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted(C₁-C₁₈) aminoalkyl, an unsubstituted arylamino-(C₁-C₁₈) alkyl, anunsubstituted (C₁-C₁₈) aminoalkyloxy, an unsubstituted (C₁-C₁₈)aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxy, an unsubstituted (C₁-C₁₈) aminoalkylaminocarbonyl, anunsubstituted (C₁-C₁₈) aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈alkyl)aminoalkyl, unsubstituted (C₁-C₁₈) guanidinoalkyloxy,unsubstituted (C₁-C₁₈) quaternaryammoniumalkylcarboxy, and unsubstituted(C₁-C₁₈) guanidinoalkyl carboxy; and R₁, R₂, R₄, R₅, R₆, R₈, R₉, R₁₀,R₁₁, R₁₃, R₁₄, R₁₅, R₁₆, and R₁₇ are independently selected from thegroup consisting of hydrogen and unsubstituted (C₁-C₆) alkyl.

In some embodiments, R₃, R₇, R₁₂, and R₁₈ are independently selectedfrom the group consisting of hydrogen, an unsubstituted (C₁-C₆) alkyl,unsubstituted (C₁-C₆) hydroxyalkyl, unsubstituted (C₁-C₁₆)alkyloxy-(C₁-C₅) alkyl, unsubstituted (C₁-C₁₆) alkylcarboxy-(C₁-C₅)alkyl, unsubstituted (C₁-C₁₆) alkylamino-(C₁-C₅) alkyl, (C₁-C₁₆)alkylamino-(C₁-C₅) alkylamino, unsubstituted (C₁-C₁₆)alkylamino-(C₁-C₁₆) alkylamino-(C₁-C₅) alkylamino, an unsubstituted(C₁-C₁₆) aminoalkyl, an unsubstituted arylamino-(C₁-C₅) alkyl, anunsubstituted (C₁-C₅) aminoalkyloxy, an unsubstituted (C₁-C₁₆)aminoalkyloxy-(C₁-C₅) alkyl, an unsubstituted (C₁-C₅) aminoalkylcarboxy,an unsubstituted (C₁-C₅) aminoalkylaminocarbonyl, an unsubstituted(C₁-C₅) aminoalkylcarboxamido, an unsubstituted di(C₁-C₅alkyl)amino-(C₁-C₅) alkyl, unsubstituted (C₁-C₅) guanidinoalkyloxy,unsubstituted (C₁-C₁₆) quaternaryammoniumalkylcarboxy, and unsubstituted(C₁-C₁₆) guanidinoalkylcarboxy.

In some embodiments, R₁, R₂, R₄, R₅, R₆, R₈, R₁₀, R₁₁, R₁₄, R₁₆, and R₁₇are each hydrogen; and R₉ and R₁₃ are each methyl. In some embodiments,R₃, R₇, R₁₂, and R₁₈ are independently selected from the groupconsisting of aminoalkyloxy; aminoalkylcarboxy; alkylaminoalkyl;alkoxycarbonylalkyl; alkylcarbonylalkyl; di(alkyl)aminoalkyl;alkoxycarbonylalkyl; and alkylcarboxyalkyl. In some embodiments, R₃, R₇,and R₁₂ are independently selected from the group consisting ofaminoalkyloxy and aminoalkylcarboxy; and R₁₈ is selected from the groupconsisting of alkylaminoalkyl; alkoxycarbonylalkyl;alkylcarbonyloxyalkyl; di(alkyl)aminoalkyl; alkylaminoalkyl;alkyoxycarbonylalkyl; and alkylcarboxyalkyl. In some embodiments, R₃,R₇, and R₁₂ are the same. In some embodiments, R₃, R₇, and R₁₂ areaminoalkyloxy. In some embodiments, R₁₈ is alkylaminoalkyl. In someembodiments, R₁₈ is alkoxycarbonylalkyl. In some embodiments, R₁₈ isdi(alkyl)aminoalkyl. In some embodiments, R₁₈ is alkylcarboxyalkyl. Insome embodiments, R₃, R₇, and R₁₂ are aminoalkylcarboxy. In someembodiments, R₁₈ is alkylaminoalkyl. In some embodiments, R₁₈ isalkoxycarbonylalkyl. In some embodiments, R₁₈ is di(alkyl)aminoalkyl. Insome embodiments, R₁₈ is alkylcarboxyalkyl. In some embodiments, R₃, R₇,R₁₂, and R₁₈ are independently selected from the group consisting ofamino-C₃-alkyloxy; amino-C₃-alkyl-carboxy; C₈-alkylamino-C₅-alkyl;C₈-alkoxy-carbonyl-C₄-alkyl; C₁₀-alkoxy-carbonyl-C₄-alkyl;C₈-alkyl-carbonyl-C₄-alkyl; di-(C₅-alkyl)amino-C₅-alkyl;C₁₃-alkylamino-C₅-alkyl; C₆-alkoxy-carbonyl-C₄-alkyl;C₆-alkyl-carboxy-C₄-alkyl; and C₁₆-alkylamino-C₅-alkyl. In someembodiments, m, n, and p, are each 1 and q is 0.

In some embodiments, the CSA, or a pharmaceutically acceptable saltthereof, is selected from the compound of Formula (III):

In some embodiments, the CSA, or a pharmaceutically acceptable saltthereof, is selected from the group consisting of:

In some embodiments, the compound of Formula (III), or apharmaceutically acceptable salt thereof, is

In some embodiments, the compound of Formula (III), or apharmaceutically acceptable salt thereof, is

In some embodiments, the compound of Formula (III), or apharmaceutically acceptable salt thereof, is

In some embodiments, the compound of Formula (III), or apharmaceutically acceptable salt thereof, is

In some embodiments, the pharmaceutically acceptable salt is ahydrochloride salt. In some embodiments, the pharmaceutically acceptablesalt is a mono-hydrochloride salt, a di-hydrochloride salt, atri-hydrochloride salt, or a tetra-hydrochloride salt. In someembodiments, the method further comprises administering an antibiotic tothe patient. In some embodiments, the antibiotic is a second CSA. Inother embodiments, the antibiotic is a non-CSA antibiotic.

In some embodiments, an antibiotic is further administered. In someembodiments, the antibiotic is selected from the group consisting of anaminoglycoside, an ansamycin, a carbacephem, a carbapenem, acephalosporin, a glycopeptide, a lincosamide, a lipopeptide, amacrolide, a monbactam, a nitrofuran, an oxazolidonone, a penicillin, apolypeptide, a quinolone, a sulfonamide, and a tetracycline.

In some embodiments, the method further comprises administering anon-CSA anti-inflammatory agent.

In some embodiments, the CSA inhibits resorption of the alveolar bone.In some embodiments, the CSA inhibits inflammation. In some embodiments,the CSA inhibits inflammation mediated by a tumor necrosis factor.

In some embodiments, the CSA is complexed with albumin or a surfactant.In some embodiments, the CSA is complexed with one or more poloxamersurfactant. In some embodiments, the one or more poloxamer surfactant isa flake poloxamer. In some embodiments, the one or more poloxamersurfactant has a molecular weight of about 3600 g/mol for the centralhydrophobic chain of polyoxypropylene and has about 70% polyoxyethylenecontent. In some embodiments, the ratio of the one or more poloxamer toCSA is between about 50 to 1 to about 1:50. In some embodiments, theratio of the one or more poloxamer to CSA is between about 30 to 1 toabout 3:1. In some embodiments, the one or more poloxamer is betweenabout 10% to about 40% by weight of a formulation administered to thepatient. In some embodiments, the one or more poloxamer is between about20% to about 30% by weight of the formulation. In some embodiments, theCSA is administered in a formulation containing less than about 20% byweight of CSA.

In some embodiments, the CSA is selected by measuring a biomarker orsubjecting a sample from the patient to a companion diagnostic device inthe patient. In some embodiments, the biomarker is a cellular responseto the CSA or the companion diagnostic device measures a cellularresponse to the CSA. In some embodiments, the cellular response is achange in mRNA levels associated with inflammation.

In some embodiments, the disease is oral mucositis. In anotherembodiment the disease is gingivitis. In some embodiments, the diseaseis periodontitis. In some embodiments, the disease is gastric mucositis.In some embodiments, the disease is inflammatory fibrosis. In someembodiments, the disease is gastritis. In some embodiments, the diseaseis colitis. In some embodiments, the disease is ileitis. In someembodiments, the disease is Crohn's disease. In some embodiments, thedisease is chronic inflammatory intestinal disease. In some embodiments,the disease is inflammatory bowel syndrome. In some embodiments, thedisease is chronic inflammatory bowel disease. In some embodiments, thedisease is celiac disease. In some embodiments, the disease isulcerative colitis. In some embodiments, the disease is a gastric ulcer.In some embodiments, the disease is a peptic ulcer. In some embodiments,the disease is a buccal ulcer. In some embodiments, the disease is anasopharyngeal ulcer. In some embodiments, the disease is an esophagealulcer. In some embodiments, the disease is a duodenal ulcer. In someembodiments, the disease is a gastrointestinal ulcer. In someembodiments, the disease is an autoimmune disorder. In some embodiments,the symptom is pain. In some embodiments, the symptom is pain caused,related, or associated with a disease selected from oral mucositis,gingivitis, periodontitis, gastric mucositis, gastritis, colitis,ileitis, Crohn's disease, chronic inflammatory intestinal disease,inflammatory bowel syndrome, chronic inflammatory bowel disease, cysticfibrosis, celiac disease, ulcerative colitis, a gastric ulcer, a pepticulcer, a buccal ulcer, a nasopharyngeal ulcer, an esophageal ulcer, aduodenal ulcer, a gastrointestinal ulcer.

In some embodiments, the pain is nociceptive, neuropathic, phantom,psychogenic, breakthrough pain, or incident pain. In some embodiments,the pain is acute or chronic. In some embodiments, the treating,reducing, or preventing a disease or symptom is independent of CSAantibiotic activity. In some embodiments, the patient is a mammal. Insome embodiments, the mammal is a human. Some embodiments describe a CSAcomposition, comprising CSA and one or more poloxymers. In someembodiments, the composition contains less than about 20% by weight ofCSA; and between about 10% to about 40% by weight of one or morepoloxymer. In some embodiments, the composition contains less than about10% by weight of CSA; and between about 20% to about 30% by weight ofone or more poloxymer. In some embodiments, the ratio of the one or morepoloxamer to CSA is between about 30 to 1 to about 3:1. In someembodiments, the one or more poloxamer surfactant is a flake poloxamer.In some embodiments, the one or more poloxamer surfactant has amolecular weight of about 3600 g/mol for the central hydrophobic chainof polyoxypropylene and has about 70% polyoxyethylene content. In someembodiments, the composition further comprises albumin.

DETAILED DESCRIPTION

The embodiments disclosed herein will now be described by reference tosome more detailed embodiments, with occasional reference to anyapplicable accompanying drawings. These embodiments may, however, beembodied in different forms and should not be construed as limited tothe embodiments set forth herein. Rather, these embodiments are providedso that this disclosure will be thorough and complete, and will fullyconvey the scope of the embodiments to those skilled in the art.

DEFINITIONS

Unless otherwise defined, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which these embodiments belong. The terminology used in thedescription herein is for describing particular embodiments only and isnot intended to be limiting of the embodiments. As used in thespecification and the appended claims, the singular forms “a,” “an,” and“the” are intended to include the plural forms as well, unless thecontext clearly indicates otherwise. All publications, patentapplications, patents, and other references mentioned herein areincorporated by reference in their entirety.

Terms and phrases used in this application, and variations thereof,especially in the appended claims, unless otherwise expressly stated,should be construed as open ended as opposed to limiting. As examples ofthe foregoing, the term ‘including’ should be read to mean ‘including,without limitation,’ ‘including but not limited to,’ or the like; theterm ‘comprising’ as used herein is synonymous with ‘including,’‘containing,’ or ‘characterized by,’ and is inclusive or open-ended anddoes not exclude additional, unrecited elements or method steps; theterm ‘having’ should be interpreted as ‘having at least;’ the term‘includes’ should be interpreted as ‘includes but is not limited to;’the term ‘example’ is used to provide exemplary instances of the item indiscussion, not an exhaustive or limiting list thereof; and use of termslike ‘preferably,’ ‘preferred,’ ‘desired,’ or ‘desirable,’ and words ofsimilar meaning should not be understood as implying that certainfeatures are critical, essential, or even important to the structure orfunction of the invention, but instead as merely intended to highlightalternative or additional features that may or may not be utilized in aparticular embodiment. In addition, the term “comprising” is to beinterpreted synonymously with the phrases “having at least” or“including at least”. When used in the context of a process, the term“comprising” means that the process includes at least the recited steps,but may include additional steps. When used in the context of acompound, composition or device, the term “comprising” means that thecompound, composition or device includes at least the recited featuresor components, but may also include additional features or components.Likewise, a group of items linked with the conjunction ‘and’ should notbe read as requiring that each and every one of those items be presentin the grouping, but rather should be read as ‘and/or’ unless expresslystated otherwise. Similarly, a group of items linked with theconjunction ‘or’ should not be read as requiring mutual exclusivityamong that group, but rather should be read as ‘and/or’ unless expresslystated otherwise.

It is understood that, in any compound described herein having one ormore chiral centers, if an absolute stereochemistry is not expresslyindicated, then each center may independently be of R-configuration orS-configuration or a mixture thereof. Thus, the compounds providedherein may be enantiomerically pure, enantiomerically enriched, racemicmixture, diastereomerically pure, diastereomerically enriched, or astereoisomeric mixture. In addition it is understood that, in anycompound described herein having one or more double bond(s) generatinggeometrical isomers that can be defined as E or Z, each double bond mayindependently be E or Z a mixture thereof.

Likewise, it is understood that, in any compound described, alltautomeric forms are also intended to be included.

It is to be understood that where compounds disclosed herein haveunfilled valencies, then the valencies are to be filled with hydrogensor isotopes thereof, e.g., hydrogen-1 (protium) and hydrogen-2(deuterium).

It is understood that the compounds described herein can be labeledisotopically. Substitution with isotopes such as deuterium may affordcertain therapeutic advantages resulting from greater metabolicstability, such as, for example, increased in vivo half-life or reduceddosage requirements. Each chemical element as represented in a compoundstructure may include any isotope of said element. For example, in acompound structure a hydrogen atom may be explicitly disclosed orunderstood to be present in the compound. At any position of thecompound that a hydrogen atom may be present, the hydrogen atom can beany isotope of hydrogen, including but not limited to hydrogen-1(protium) and hydrogen-2 (deuterium). Thus, reference herein to acompound encompasses all potential isotopic forms unless the contextclearly dictates otherwise.

It is understood that the methods and combinations described hereininclude crystalline forms (also known as polymorphs, which include thedifferent crystal packing arrangements of the same elemental compositionof a compound), amorphous phases, salts, solvates, and hydrates. In someembodiments, the compounds described herein exist in solvated forms withpharmaceutically acceptable solvents such as water, ethanol, or thelike. In other embodiments, the compounds described herein exist inunsolvated form. Solvates contain either stoichiometric ornon-stoichiometric amounts of a solvent, and may be formed during theprocess of crystallization with pharmaceutically acceptable solventssuch as water, ethanol, or the like. Hydrates are formed when thesolvent is water, or alcoholates are formed when the solvent is alcohol.In addition, the compounds provided herein can exist in unsolvated aswell as solvated forms. In general, the solvated forms are consideredequivalent to the unsolvated forms for the purposes of the compounds andmethods provided herein.

Unless otherwise indicated, all numbers expressing quantities ofingredients, reaction conditions, and so forth used in the specificationand claims are to be understood as being modified in all instances bythe term “about.” Accordingly, unless indicated to the contrary, thenumerical parameters set forth in the specification and attached claimsare approximations that may vary depending upon the desired propertiessought to be obtained by the present embodiments. At the very least, andnot as an attempt to limit the application of the doctrine ofequivalents to the scope of the claims, each numerical parameter shouldbe construed in light of the number of significant digits and ordinaryrounding approaches.

Notwithstanding that the numerical ranges and parameters setting forththe broad scope of the embodiments are approximations, the numericalvalues set forth in the specific examples are reported as precisely aspossible. Any numerical value, however, inherently contains certainerrors necessarily resulting from the standard deviation found in theirrespective testing measurements. Every numerical range given throughoutthis specification and claims will include every narrower numericalrange that falls within such broader numerical range, as if suchnarrower numerical ranges were all expressly written herein. Where arange of values is provided, it is understood that the upper and lowerlimit, and each intervening value between the upper and lower limit ofthe range is encompassed within the embodiments.

As used herein, the terms “antibiotic” and “antimicrobial” refer tocompounds that possess antibiotic and/or antimicrobial activity,regardless of whether the compounds have been approved for antibioticand/or antimicrobial use by a government agency.

As used herein, any “R” group(s) such as, without limitation, R¹, R²,R³, R⁴, R⁵, R⁶, R⁷, R⁸, R⁹, R¹⁰, R¹¹, R¹², R¹³, R¹⁴, R¹⁵, R¹⁶, R¹⁷, andR¹⁸ represent substituents that can be attached to the indicated atom.Unless otherwise specified, an R group may be substituted orunsubstituted.

A “ring” as used herein can be heterocyclic or carbocyclic. The term“saturated” used herein refers to a ring having each atom in the ringeither hydrogenated or substituted such that the valency of each atom isfilled. The term “unsaturated” used herein refers to a ring where thevalency of each atom of the ring may not be filled with hydrogen orother substituents. For example, adjacent carbon atoms in the fused ringcan be doubly bound to each other. Unsaturation can also includedeleting at least one of the following pairs and completing the valencyof the ring carbon atoms at these deleted positions with a double bond;such as R₅ and R₉ R₈ and R₁₀; and R₁₃ and R₁₄.

Whenever a group is described as being “substituted” that group may besubstituted with one, two, three or more of the indicated substituents,which may be the same or different, each replacing a hydrogen atom. Ifno substituents are indicated, it is meant that the indicated“substituted” group may be substituted with one or more group(s)individually and independently selected from alkyl, alkenyl, alkynyl,cycloalkyl, cycloalkenyl, cycloalkynyl, acylalkyl, alkoxyalkyl,aminoalkyl, amino acid, aryl, heteroaryl, heteroalicyclyl, aralkyl,heteroaralkyl, (heteroalicyclyl)alkyl, hydroxy, protected hydroxyl,alkoxy, aryloxy, acyl, mercapto, alkylthio, arylthio, cyano, halogen(e.g., F, Cl, Br, and I), thiocarbonyl, O-carbamyl, N-carbamyl,O-thiocarbamyl, N-thiocarbamyl, C-amido, N-amido, S-sulfonamido,N-sulfonamido, C-carboxy, protected C-carboxy, O-carboxy, isocyanato,thiocyanato, isothiocyanato, nitro, oxo, silyl, sulfenyl, sulfinyl,sulfonyl, haloalkyl, haloalkoxy, trihalomethanesulfonyl,trihalomethanesulfonamido, an amino, a mono-substituted amino group anda di-substituted amino group, R^(a)O(CH₂)_(m)O—, R^(b)(CH₂)_(n)O—,R^(c)C(O)O(CH₂)_(p)O—, and protected derivatives thereof. Thesubstituent may be attached to the group at more than one attachmentpoint. For example, an aryl group may be substituted with a heteroarylgroup at two attachment points to form a fused multicyclic aromatic ringsystem. Biphenyl and naphthalene are two examples of an aryl group thatis substituted with a second aryl group.

As used herein, “C_(a)” or “C_(a) to C_(b)” in which “a” and “b” areintegers refer to the number of carbon atoms in an alkyl, alkenyl oralkynyl group, or the number of carbon atoms in the ring of acycloalkyl, cycloalkenyl, cycloalkynyl, aryl, heteroaryl orheteroalicyclyl group. That is, the alkyl, alkenyl, alkynyl, ring of thecycloalkyl, ring of the cycloalkenyl, ring of the cycloalkynyl, ring ofthe aryl, ring of the heteroaryl or ring of the heteroalicyclyl cancontain from “a” to “b”, inclusive, carbon atoms. Thus, for example, a“C₁ to C₄ alkyl” group refers to all alkyl groups having from 1 to 4carbons, that is, CH₃—, CH₃CH₂—, CH₃CH₂CH₂—, (CH₃)₂CH—, CH₃CH₂CH₂CH₂—,CH₃CH₂CH(CH₃)— and (CH₃)₃C—. If no “a” and “b” are designated withregard to an alkyl, alkenyl, alkynyl, cycloalkyl cycloalkenyl,cycloalkynyl, aryl, heteroaryl or heteroalicyclyl group, the broadestrange described in these definitions is to be assumed.

As used herein, “alkyl” refers to a straight or branched hydrocarbonchain that comprises a fully saturated (no double or triple bonds)hydrocarbon group. The alkyl group may have 1 to 25 carbon atoms(whenever it appears herein, a numerical range such as “1 to 25” refersto each integer in the given range; e.g., “1 to 25 carbon atoms” meansthat the alkyl group may consist of 1 carbon atom, 2 carbon atoms, 3carbon atoms, etc., up to and including 25 carbon atoms, although thepresent definition also covers the occurrence of the term “alkyl” whereno numerical range is designated). The alkyl group may also be a mediumsize alkyl having 1 to 15 carbon atoms. The alkyl group could also be alower alkyl having 1 to 6 carbon atoms. The alkyl group of the compoundsmay be designated as “C₄” or “C₁-C₄ alkyl” or similar designations. Byway of example only, “C₁-C₄ alkyl” indicates that there are one to fourcarbon atoms in the alkyl chain, i.e., the alkyl chain is selected frommethyl, ethyl, propyl, iso-propyl, n-butyl, iso-butyl, sec-butyl, andt-butyl. Typical alkyl groups include, but are in no way limited to,methyl, ethyl, propyl, isopropyl, butyl, isobutyl, tertiary butyl,pentyl and hexyl. The alkyl group may be substituted or unsubstituted.

As used herein, “alkenyl” refers to an alkyl group that contains in thestraight or branched hydrocarbon chain one or more double bonds. Thealkenyl group may have 2 to 25 carbon atoms (whenever it appears herein,a numerical range such as “2 to 25” refers to each integer in the givenrange; e.g., “2 to 25 carbon atoms” means that the alkenyl group mayconsist of 2 carbon atom, 3 carbon atoms, 4 carbon atoms, etc., up toand including 25 carbon atoms, although the present definition alsocovers the occurrence of the term “alkenyl” where no numerical range isdesignated). The alkenyl group may also be a medium size alkenyl having2 to 15 carbon atoms. The alkenyl group could also be a lower alkenylhaving 1 to 6 carbon atoms. The alkenyl group of the compounds may bedesignated as “C₄” or “C₂-C₄ alkyl” or similar designations. An alkenylgroup may be unsubstituted or substituted.

As used herein, “alkynyl” refers to an alkyl group that contains in thestraight or branched hydrocarbon chain one or more triple bonds. Thealkynyl group may have 2 to 25 carbon atoms (whenever it appears herein,a numerical range such as “2 to 25” refers to each integer in the givenrange; e.g., “2 to 25 carbon atoms” means that the alkynyl group mayconsist of 2 carbon atom, 3 carbon atoms, 4 carbon atoms, etc., up toand including 25 carbon atoms, although the present definition alsocovers the occurrence of the term “alkynyl” where no numerical range isdesignated). The alkynyl group may also be a medium size alkynyl having2 to 15 carbon atoms. The alkynyl group could also be a lower alkynylhaving 2 to 6 carbon atoms. The alkynyl group of the compounds may bedesignated as “C₄” or “C₂-C₄ alkyl” or similar designations. An alkynylgroup may be unsubstituted or substituted.

As used herein, “aryl” refers to a carbocyclic (all carbon) monocyclicor multicyclic aromatic ring system (including fused ring systems wheretwo carbocyclic rings share a chemical bond) that has a fullydelocalized pi-electron system throughout all the rings. The number ofcarbon atoms in an aryl group can vary. For example, the aryl group canbe a C₆-C₁₄ aryl group, a C₆-C₁₀ aryl group, or a C₆ aryl group(although the definition of C₆-C₁₀ aryl covers the occurrence of “aryl”when no numerical range is designated). Examples of aryl groups include,but are not limited to, benzene, naphthalene and azulene. An aryl groupmay be substituted or unsubstituted.

As used herein, “aralkyl” and “aryl(alkyl)” refer to an aryl groupconnected, as a substituent, via a lower alkylene group. The aralkylgroup may have 6 to 20 carbon atoms (whenever it appears herein, anumerical range such as “6 to 20” refers to each integer in the givenrange; e.g., “6 to 20 carbon atoms” means that the aralkyl group mayconsist of 6 carbon atom, 7 carbon atoms, 8 carbon atoms, etc., up toand including 20 carbon atoms, although the present definition alsocovers the occurrence of the term “aralkyl” where no numerical range isdesignated). The lower alkylene and aryl group of an aralkyl may besubstituted or unsubstituted. Examples include but are not limited tobenzyl, 2-phenylalkyl, 3-phenylalkyl, and naphthylalkyl.

“Lower alkylene groups” refer to a C₁-C₂₅ straight-chained alkyltethering groups, such as —CH₂— tethering groups, forming bonds toconnect molecular fragments via their terminal carbon atoms. Examplesinclude but are not limited to methylene (—CH₂—), ethylene (—CH₂CH₂—),propylene (—CH₂CH₂CH₂—), and butylene (—CH₂CH₂CH₂CH₂—). A lower alkylenegroup can be substituted by replacing one or more hydrogen of the loweralkylene group with a substituent(s) listed under the definition of“substituted.”

As used herein, “cycloalkyl” refers to a completely saturated (no doubleor triple bonds) mono- or multi-cyclic hydrocarbon ring system. Whencomposed of two or more rings, the rings may be joined together in afused fashion. Cycloalkyl groups can contain 3 to 10 atoms in thering(s) or 3 to 8 atoms in the ring(s). A cycloalkyl group may beunsubstituted or substituted. Typical cycloalkyl groups include, but arein no way limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl,cycloheptyl and cyclooctyl.

As used herein, “cycloalkenyl” refers to a mono- or multi-cyclichydrocarbon ring system that contains one or more double bonds in atleast one ring; although, if there is more than one, the double bondscannot form a fully delocalized pi-electron system throughout all therings (otherwise the group would be “aryl,” as defined herein). Whencomposed of two or more rings, the rings may be connected together in afused fashion. A cycloalkenyl group may be unsubstituted or substituted.

As used herein, “cycloalkynyl” refers to a mono- or multi-cyclichydrocarbon ring system that contains one or more triple bonds in atleast one ring. If there is more than one triple bond, the triple bondscannot form a fully delocalized pi-electron system throughout all therings. When composed of two or more rings, the rings may be joinedtogether in a fused fashion. A cycloalkynyl group may be unsubstitutedor substituted.

As used herein, “alkoxy” or “alkyloxy” refers to the formula —OR whereinR is an alkyl, an alkenyl, an alkynyl, a cycloalkyl, a cycloalkenyl or acycloalkynyl as defined above. A non-limiting list of alkoxys aremethoxy, ethoxy, n-propoxy, 1-methylethoxy (isopropoxy), n-butoxy,iso-butoxy, sec-butoxy and tert-butoxy. An alkoxy may be substituted orunsubstituted.

As used herein, “acyl” refers to a hydrogen, alkyl, alkenyl, alkynyl,aryl, or heteroaryl connected, as substituents, via a carbonyl group.Examples include formyl, acetyl, propanoyl, benzoyl, and acryl. An acylmay be substituted or unsubstituted.

As used herein, “alkoxyalkyl” or “alkyloxyalkyl” refers to an alkoxygroup connected, as a substituent, via a lower alkylene group. Examplesinclude alkyl-O-alkyl- and alkoxy-alkyl- with the terms alkyl and alkoxydefined herein.

As used herein, “hydroxyalkyl” refers to an alkyl group in which one ormore of the hydrogen atoms are replaced by a hydroxy group. Exemplaryhydroxyalkyl groups include but are not limited to, 2-hydroxyethyl,3-hydroxypropyl, 2-hydroxypropyl, and 2,2-dihydroxyethyl. A hydroxyalkylmay be substituted or unsubstituted.

As used herein, “haloalkyl” refers to an alkyl group in which one ormore of the hydrogen atoms are replaced by a halogen (e.g.,mono-haloalkyl, di-haloalkyl and tri-haloalkyl). Such groups include butare not limited to, chloromethyl, fluoromethyl, difluoromethyl,trifluoromethyl and 1-chloro-2-fluoromethyl, 2-fluoroisobutyl. Ahaloalkyl may be substituted or unsubstituted.

The term “amino” as used herein refers to a —NH₂ group.

As used herein, the term “hydroxy” refers to a —OH group.

A “cyano” group refers to a “—CN” group.

A “carbonyl” or an “oxo” group refers to a C═O group.

The term “azido” as used herein refers to a —N₃ group.

As used herein, “aminoalkyl” refers to an amino group connected, as asubstituent, via a lower alkylene group. Examples include H₂N-alkyl-with the term alkyl defined herein.

As used herein, “alkylcarboxyalkyl” refers to an alkyl group connected,as a substituent, to a carboxy group that is connected, as asubstituent, to an alkyl group. Examples include alkyl-C(═O)O-alkyl- andalkyl-O—C(═O)-alkyl- with the term alkyl as defined herein.

As used herein, “alkylaminoalkyl” refers to an alkyl group connected, asa substituent, to an amino group that is connected, as a substituent, toan alkyl group. Examples include alkyl-NH-alkyl-, with the term alkyl asdefined herein.

As used herein, “dialkylaminoalkyl” or “di(alkyl)aminoalkyl” refers totwo alkyl groups connected, each as a substituent, to an amino groupthat is connected, as a substituent, to an alkyl group. Examples include

with the term alkyl as defined herein.

As used herein, “alkylaminoalkylamino” refers to an alkyl groupconnected, as a substituent, to an amino group that is connected, as asubstituent, to an alkyl group that is connected, as a substituent, toan amino group. Examples include alkyl-NH-alkyl-NH—, with the term alkylas defined herein.

As used herein, “alkylaminoalkylaminoalkylamino” refers to an alkylgroup connected, as a substituent, to an amino group that is connected,as a substituent, to an alkyl group that is connected, as a substituent,to an amino group that is connected, as a substituent, to an alkylgroup. Examples include alkyl-NH-alkyl-NH-alkyl-, with the term alkyl asdefined herein.

As used herein, “arylaminoalkyl” refers to an aryl group connected, as asubstituent, to an amino group that is connected, as a substituent, toan alkyl group. Examples include aryl-NH-alkyl-, with the terms aryl andalkyl as defined herein.

As used herein, “aminoalkyloxy” refers to an amino group connected, as asubstituent, to an alkyloxy group. Examples include H₂N-alkyl-O— andH₂N-alkoxy- with the terms alkyl and alkoxy as defined herein.

As used herein, “aminoalkyloxyalkyl” refers to an amino group connected,as a substituent, to an alkyloxy group connected, as a substituent, toan alkyl group. Examples include H₂N-alkyl-O-alkyl- andH₂N-alkoxy-alkyl- with the terms alkyl and alkoxy as defined herein.

As used herein, “aminoalkylcarboxy” refers to an amino group connected,as a substituent, to an alkyl group connected, as a substituent, to acarboxy group. Examples include H₂N-alkyl-C(═O)O— and H₂N-alkyl-O—C(═O)—with the term alkyl as defined herein.

As used herein, “aminoalkylaminocarbonyl” refers to an amino groupconnected, as a substituent, to an alkyl group connected, as asubstituent, to an amino group connected, as a substituent, to acarbonyl group. Examples include H₂N-alkyl-NH—C(═O)— with the term alkylas defined herein.

As used herein, “aminoalkylcarboxamido” refers to an amino groupconnected, as a substituent, to an alkyl group connected, as asubstituent, to a carbonyl group connected, as a substituent to an aminogroup. Examples include H₂N-alkyl-C(═O)—NH— with the term alkyl asdefined herein.

As used herein, “azidoalkyloxy” refers to an azido group connected as asubstituent, to an alkyloxy group. Examples include N₃-alkyl-O— andN₃-alkoxy- with the terms alkyl and alkoxy as defined herein.

As used herein, “cyanoalkyloxy” refers to a cyano group connected as asubstituent, to an alkyloxy group. Examples include NC-alkyl-O— andNC-alkoxy- with the terms alkyl and alkoxy as defined herein.

As used herein, “guanidinoalkyloxy” refers to a guanidinyl groupconnected, as a substituent, to an alkyloxy group. Examples include

with the terms alkyl and alkoxy as defined herein.

As used herein, “guanidinoalkylcarboxy” refers to a guanidinyl groupconnected, as a substituent, to an alkyl group connected, as asubstituent, to a carboxy group. Examples include

with the term alkyl as defined herein.

As used herein, “quaternaryammoniumalkylcarboxy” refers to a quaternizedamino group connected, as a substituent, to an alkyl group connected, asa substituent, to a carboxy group. Examples include

with the term alkyl as defined herein.

The term “halogen atom” or “halogen” as used herein, means any one ofthe radio-stable atoms of column 7 of the Periodic Table of theElements, such as, fluorine, chlorine, bromine and iodine.

Where the numbers of substituents is not specified (e.g. haloalkyl),there may be one or more substituents present. For example “haloalkyl”may include one or more of the same or different halogens.

As used herein, the term “amino acid” refers to any amino acid (bothstandard and non-standard amino acids), including, but not limited to,α-amino acids, β-amino acids, γ-amino acids and δ-amino acids. Examplesof suitable amino acids include, but are not limited to, alanine,asparagine, aspartate, cysteine, glutamate, glutamine, glycine, proline,serine, tyrosine, arginine, histidine, isoleucine, leucine, lysine,methionine, phenylalanine, threonine, tryptophan and valine. Additionalexamples of suitable amino acids include, but are not limited to,ornithine, hypusine, 2-aminoisobutyric acid, dehydroalanine,gamma-aminobutyric acid, citrulline, beta-alanine, alpha-ethyl-glycine,alpha-propyl-glycine and norleucine.

A linking group is a divalent moiety used to link one steroid to anothersteroid. In some embodiments, the linking group is used to link a firstCSA with a second CSA (which may be the same or different). An exampleof a linking group is (C₁-C₁₀) alkyloxy-(C₁-C₁₀) alkyl.

The terms “P.G.” or “protecting group” or “protecting groups” as usedherein refer to any atom or group of atoms that is added to a moleculein order to prevent existing groups in the molecule from undergoingunwanted chemical reactions. Examples of protecting group moieties aredescribed in T. W. Greene and P. G. M. Wuts, Protective Groups inOrganic Synthesis, 3. Ed. John Wiley & Sons, 1999, and in J. F. W.McOmie, Protective Groups in Organic Chemistry Plenum Press, 1973, bothof which are hereby incorporated by reference for the limited purpose ofdisclosing suitable protecting groups. The protecting group moiety maybe chosen in such a way, that they are stable to certain reactionconditions and readily removed at a convenient stage using methodologyknown from the art. A non-limiting list of protecting groups includebenzyl; substituted benzyl; alkylcarbonyls and alkoxycarbonyls (e.g.,t-butoxycarbonyl (BOC), acetyl, or isobutyryl); arylalkylcarbonyls andarylalkoxycarbonyls (e.g., benzyloxycarbonyl); substituted methyl ether(e.g. methoxymethyl ether); substituted ethyl ether; a substitutedbenzyl ether; tetrahydropyranyl ether; silyls (e.g., trimethylsilyl,triethylsilyl, triisopropylsilyl, t-butyldimethylsilyl,tri-iso-propylsilyloxymethyl, [2-(trimethylsilyl)ethoxy]methyl ort-butyldiphenylsilyl); esters (e.g. benzoate ester); carbonates (e.g.methoxymethylcarbonate); sulfonates (e.g. tosylate or mesylate); acyclicketal (e.g. dimethyl acetal); cyclic ketals (e.g., 1,3-dioxane,1,3-dioxolanes, and those described herein); acyclic acetal; cyclicacetal (e.g., those described herein); acyclic hemiacetal; cyclichemiacetal; cyclic dithioketals (e.g., 1,3-dithiane or 1,3-dithiolane);orthoesters (e.g., those described herein) and triarylmethyl groups(e.g., trityl; monomethoxytrityl (MMTr); 4,4′-dimethoxytrityl (DMTr);4,4′,4″-trimethoxytrityl (TMTr); and those described herein).Amino-protecting groups are known to those skilled in the art. Ingeneral, the species of protecting group is not critical, provided thatit is stable to the conditions of any subsequent reaction(s) on otherpositions of the compound and can be removed at the appropriate pointwithout adversely affecting the remainder of the molecule. In addition,a protecting group may be substituted for another after substantivesynthetic transformations are complete. Clearly, where a compounddiffers from a compound disclosed herein only in that one or moreprotecting groups of the disclosed compound has been substituted with adifferent protecting group, that compound is within the disclosure.

Compounds:

Compounds useful in accordance with this disclosure are describedherein, both generically and with particularity, and in U.S. Pat. Nos.6,350,738, 6,486,148, 6,767,904, 7,598,234, and 7,754,705, which areincorporated herein by reference. Compounds include steroid derivatives,such as cationic steroidal antimicrobials (“CSAs” and also referred toas ceragenins or cationic selective antimicrobials) that exhibit one ormore anti-inflammatory properties, autoimmune relieving properties, orpain relieving properties relevant to treating, reducing, or preventinga disease or symptom such as oral mucositis, gingivitis, periodontitis,gastric mucositis, inflammatory fibrosis, gastritis, colitis, ileitis,Crohn's disease, chronic inflammatory intestinal disease, inflammatorybowel syndrome, chronic inflammatory bowel disease, cystic fibrosis,celiac disease, ulcerative colitis, a gastric ulcer, a peptic ulcer, abuccal ulcer, a nasopharyngeal ulcer, an esophageal ulcer, a duodenalulcer, a gastrointestinal ulcer, an autoimmune disorder, and/or pain.The skilled artisan will recognize the compounds within the genericformula set forth herein. Additional compounds of the disclosure havingone or more anti-inflammatory properties, autoimmune relievingproperties, or pain relieving properties relevant to treating, reducing,or preventing a disease or symptom such as oral mucositis, gingivitis,periodontitis, gastric mucositis, inflammatory fibrosis, gastritis,colitis, ileitis, Crohn's disease, chronic inflammatory intestinaldisease, inflammatory bowel syndrome, chronic inflammatory boweldisease, cystic fibrosis, celiac disease, ulcerative colitis, a gastriculcer, a peptic ulcer, a buccal ulcer, a nasopharyngeal ulcer, anesophageal ulcer, a duodenal ulcer, a gastrointestinal ulcer, anautoimmune disorder, and/or pain are described and can be characterizedusing the assays set forth herein and in the art.

Methods and Uses:

We have discovered that CSAs are useful for modulating inflammatoryresponses. Accordingly, disclosed herein are methods of treating,reducing, or inhibiting inflammation or inflammatory responses byadministering one or more CSAs to a patient in need thereof. During thecourse of our discovery, we also found that CSAs are useful for treatingpain associated with inflammation. In particular, we have discoveredthat CSAs are useful for treating one or more of oral mucositis,gingivitis, periodontitis, gastric mucositis, inflammatory fibrosis,gastritis, colitis, ileitis, Crohn's disease, chronic inflammatoryintestinal disease, inflammatory bowel syndrome, chronic inflammatorybowel disease, celiac disease, ulcerative colitis, a gastric ulcer, apeptic ulcer, a buccal ulcer, a nasopharyngeal ulcer, an esophagealulcer, a duodenal ulcer or a gastrointestinal ulcer, or pain associatedwith said diseases. Several of these diseases are autoimmune disorders.As previously and generally described, an autoimmune disorder involves acondition that occurs when the immune system mistakenly attacks anddestroys healthy body tissue. Such autoimmune disorders include celiacdisease, certain types of arthritis (such as reative and rheumatoid),Graves diseases, etc.

Disclosed herein are methods of treating diseases selected from oralmucositis, gingivitis, periodontitis, gastric mucositis, inflammatoryfibrosis, gastritis, colitis, ileitis, Crohn's disease, chronicinflammatory intestinal disease, inflammatory bowel syndrome, chronicinflammatory bowel disease, celiac disease, ulcerative colitis, agastric ulcer, a peptic ulcer, a buccal ulcer, a nasopharyngeal ulcer,an esophageal ulcer, a duodenal ulcer, or a gastrointestinal ulcercomprising identifying a patient in need of treatment and administeringa therapeutically effective amount of at least one cationic steroidalantimicrobial (CSA), or a pharmaceutically acceptable salt thereof.Disclosed herein are also methods of reducing, treating, or alleviatingpain associated, derived, or caused by oral mucositis, gingivitis,periodontitis, gastric mucositis, gastritis, colitis, ileitis, Crohn'sdisease, chronic inflammatory intestinal disease, inflammatory bowelsyndrome, chronic inflammatory bowel disease, celiac disease, ulcerativecolitis, a gastric ulcer, a peptic ulcer, a buccal ulcer, anasopharyngeal ulcer, an esophageal ulcer, a duodenal ulcer or agastrointestinal ulcer. Disclosed herein are also methods of reducing,treating, or alleviating an autoimmune disorder.

Cystic fibrosis is characterized by recurrent lung infections andchronic inflammation in infected lung tissues. IL-6 is a marker for suchinfection. Treatment with CSAs can reduce IL-6 levels; and suchreduction of IL-6 and/or other pro-inflammatory cytokines in cysticfibrosis patients can reduce the severity of cystic fibrosis symptoms,reduce lung scarring and other long-term adverse consequences, andimprove patient comfort and quality of life.

Moreover, our initial observations regarding pain have led to thesurprising discovery that CSAs are effective at managing pain ingeneral, as opposed to pain associated with inflammation. Accordingly,disclosed herein are methods of treating, reducing, or preventing paincomprising identifying a patient in need of said treatment andadministering a therapeutically effective amount of at least onecationic steroidal antimicrobial (CSA), or a pharmaceutically acceptablesat thereof. In some embodiments, the pain is nociceptive, neuropathic,phantom, psychogenic, breakthrough pain, or incident pain. In someembodiments, the pain is acute. In other embodiments, the pain ischronic. In some embodiments, the pain is a trigger point producingpain. In other embodiments, the pain is a sympathetic dystrophy. In someembodiments, the patient suffering from pain has tried one or moreunsuccessful pain remedies (such as acupuncture or drugs such asopioids).

Some embodiments are a method of treating, reducing, or preventing adisease or symptom selected from oral mucositis, gingivitis,periodontitis, gastric mucositis, inflammatory fibrosis, gastritis,colitis, ileitis, Crohn's disease, chronic inflammatory intestinaldisease, inflammatory bowel syndrome, chronic inflammatory boweldisease, celiac disease, ulcerative colitis, a gastric ulcer, a pepticulcer, a buccal ulcer, a nasopharyngeal ulcer, an esophageal ulcer, aduodenal ulcer, a gastrointestinal ulcer, an autoimmune disorder, orpain, comprising: identifying a patient in need of treating, reducing,or preventing a disease or symptom selected from oral mucositis,gingivitis, periodontitis, gastric mucositis, gastritis, colitis,ileitis, Crohn's disease, chronic inflammatory intestinal disease,inflammatory bowel syndrome, chronic inflammatory bowel disease, cysticfibrosis, celiac disease, ulcerative colitis, a gastric ulcer, a pepticulcer, a buccal ulcer, a nasopharyngeal ulcer, an esophageal ulcer, aduodenal ulcer, a gastrointestinal ulcer, an autoimmune disorder, orpain; and administering a therapeutically effective amount of at leastone cationic steroidal antimicrobial (CSA), or a pharmaceuticallyacceptable sat thereof.

In some embodiments, a therapeutically effective amount of at least onecationic steroidal antimicrobial (CSA), or a pharmaceutically acceptablesalt thereof is administered to treat oral inflammatory diseases. Suchdiseases specifically include oral mucositis, gingivitis andperiodontitis. In some embodiments, CSAs are administered to preventsuch oral inflammatory diseases, specifically oral mucositis, gingivitisor periodontitis. In other embodiments, a therapeutically effectiveamount of at least one cationic steroidal antimicrobial (CSA), or apharmaceutically acceptable salt thereof is administered to treatgastric mucositis, inflammatory fibrosis, gastritis, colitis, ileitis,Crohn's disease, chronic inflammatory intestinal disease, inflammatorybowel syndrome, chronic inflammatory bowel disease, celiac disease,ulcerative colitis, a gastric ulcer, a peptic ulcer, a buccal ulcer, anasopharyngeal ulcer, an esophageal ulcer, a duodenal ulcer, anautoimmune disorder, and a gastrointestinal ulcer. In some embodiments,CSAs are administered to prevent such diseases, specifically gastricmucositis, gastritis, colitis, ileitis, and ulcer development. In someembodiments, CSAs are administered to treat pain associated with thesediseases.

Some embodiments are methods of reducing, or preventing a diseaseselected from oral mucositis, gastric mucositis, or inflammatoryfibrosis comprising identifying a patient in need of treating, reducing,or preventing a disease selected from oral mucositis, gastric mucositis,or inflammatory fibrosis and administering a therapeutically orprophylactically effective amount of at least one cationic steroidalantimicrobial (CSA), or a pharmaceutically acceptable salt thereof totreat, reduce, or prevent said disease. In some embodiments, thepharmaceutically acceptable salt is a mono-hydrochloride salt, adi-hydrochloride salt, a tri-hydrochloride salt, or atetra-hydrochloride salt.

In some embodiments, the methods of reducing, or preventing a diseasefurther comprise administering an antibiotic to the patient, wherein theantibiotic is selected from the group consisting of an aminoglycoside,an ansamycin, a carbacephem, a carbapenem, a cephalosporin, aglycopeptide, a lincosamide, a lipopeptide, a macrolide, a monbactam, anitrofuran, an oxazolidonone, a penicillin, a polypeptide, a quinolone,a sulfonamide, and a tetracycline. In some embodiments, the methods ofreducing, or preventing a disease further comprise administering anon-CSA anti-inflammatory agent.

In some embodiments, the CSA is complexed with albumin or a surfactant.In some embodiments, the CSA is complexed with one or more poloxamersurfactant. In some embodiments, the one or more poloxamer surfactanthas a molecular weight of about 3600 g/mol for the central hydrophobicchain of polyoxypropylene and has about 70% polyoxyethylene content. Insome embodiments, the ratio of the one or more poloxamer to CSA isbetween about 50 to 1 to about 1 to 50 or between about 30 to 1 to about3 to 1. In some embodiments, the one or more poloxamer is between about10% to about 40% by weight or between about 20% to about 30% by weightof a formulation administered to the patient. In some embodiments, theCSA is administered in a formulation containing less than about 20% byweight of CSA.

In some embodiments, the CSA is selected by measuring a biomarker orsubjecting a sample from the patient to a companion diagnostic test. Insome embodiments, the biomarker is a cellular response to the CSA or thecompanion diagnostic test measures a cellular response to the CSA. Insome embodiments, the biomarker is selected from the group consisting ofIL-1A, IL-1B, IL-6, TLR2, TLR4, TLR6, TLR8, TLR9, TNFRSF1A, TNF,TNF-beta 1, CCL2, CXCR4, IRAK2, NFKB1, NFKB2, NFKB1A, and miR-29d.

In some embodiments, the disease is oral mucositis. In some embodiments,the disease is gastric mucositis. In some embodiments, the disease isinflammatory fibrosis. In some embodiments, the treating, reducing, orpreventing a disease is independent of CSA antibiotic activity. In someembodiments, the patient is a mammal. In some embodiments, the mammal isa human.

Some embodiments disclosed herein relate to a method of treating,reducing, or preventing a disease or symptom selected from oralmucositis, gingivitis, periodontitis, gastric mucositis, inflammatoryfibrosis, gastritis, colitis, ileitis, Crohn's disease, chronicinflammatory intestinal disease, inflammatory bowel syndrome, chronicinflammatory bowel disease, celiac disease, ulcerative colitis, agastric ulcer, a peptic ulcer, a buccal ulcer, a nasopharyngeal ulcer,an esophageal ulcer, a duodenal ulcer, a gastrointestinal ulcer, anautoimmune disorder, or pain comprising administering a compound ofFormula (I) or a pharmaceutically acceptable salt thereof:

wherein rings A, B, C, and D are independently saturated, or are fullyor partially unsaturated, provided that at least two of rings A, B, C,and D are saturated; m, n, p, and q are independently 0 or 1; R₁ throughR₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, and R₁₈ are independently selected fromthe group consisting of hydrogen, hydroxyl, a substituted orunsubstituted alkyl, substituted or unsubstituted hydroxyalkyl,substituted or unsubstituted alkyloxyalkyl, substituted or unsubstitutedalkylcarboxyalkyl, substituted or unsubstituted alkylaminoalkyl,substituted or unsubstituted alkylaminoalkylamino, substituted orunsubstituted alkylaminoalkylaminoalkylamino, a substituted orunsubstituted aminoalkyl, a substituted or unsubstituted aryl, asubstituted or unsubstituted arylaminoalkyl, substituted orunsubstituted haloalkyl, substituted or unsubstituted alkenyl,substituted or unsubstituted alkynyl, oxo, a linking group attached to asecond steroid, a substituted or unsubstituted aminoalkyloxy, asubstituted or unsubstituted aminoalkyloxyalkyl, a substituted orunsubstituted aminoalkylcarboxy, a substituted or unsubstitutedaminoalkylaminocarbonyl, a substituted or unsubstitutedaminoalkylcarboxamido, a substituted or unsubstituteddi(alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—, H₂N—HC(Q₅)-C(O)—N(H)—,substituted or unsubstituted azidoalkyloxy, substituted or unsubstitutedcyanoalkyloxy, P.G.-HN—HC(Q₅)-C(O)—O—, substituted or unsubstitutedguanidinoalkyloxy, substituted or unsubstitutedquaternaryammoniumalkylcarboxy, and substituted or unsubstitutedguanidinoalkyl carboxy, where Q₅ is a side chain of any amino acid(including a side chain of glycine, i.e., H), and P.G. is an aminoprotecting group; and R₅, R₈, R₉, R₁₀, R₁₃, R₁₄ and R₁₇ areindependently deleted when one of rings A, B, C, or D is unsaturated soas to complete the valency of the carbon atom at that site, or R₅, R₈,R₉, R₁₀, R₁₃, and R₁₄ are independently selected from the groupconsisting of hydrogen, hydroxyl, a substituted or unsubstituted alkyl,substituted or unsubstituted hydroxyalkyl, substituted or unsubstitutedalkyloxyalkyl, a substituted or unsubstituted aminoalkyl, a substitutedor unsubstituted aryl, substituted or unsubstituted haloalkyl,substituted or unsubstituted alkenyl, substituted or unsubstitutedalkynyl, oxo, a linking group attached to a second steroid, asubstituted or unsubstituted aminoalkyloxy, a substituted orunsubstituted aminoalkylcarboxy, a substituted or unsubstitutedaminoalkylaminocarbonyl, a substituted or unsubstituteddi(alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—, H₂N—HC(Q₅)-C(O)—N(H)—,substituted or unsubstituted azidoalkyloxy, substituted or unsubstitutedcyanoalkyloxy, P.G.-HN—HC(Q₅)-C(O)—O—, substituted or unsubstitutedguanidinoalkyloxy, and substituted or unsubstitutedguanidinoalkylcarboxy, where Q₅ is a side chain of any amino acid, P.G.is an amino protecting group; provided that at least two or three ofR₁₋₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, R₁₇, and R₁₈ are independentlyselected from the group consisting of a substituted or unsubstitutedaminoalkyl, a substituted or unsubstituted aminoalkyloxy, substituted orunsubstituted alkylcarboxyalkyl, substituted or unsubstitutedalkylaminoalkylamino, substituted or unsubstitutedalkylaminoalkylaminoalkylamino, a substituted or unsubstitutedaminoalkylcarboxy, a substituted or unsubstituted arylaminoalkyl, asubstituted or unsubstituted aminoalkyloxyaminoalkylaminocarbonyl, asubstituted or unsubstituted aminoalkylaminocarbonyl, a substituted orunsubstituted aminoalkylcarboxyamido, a substituted or unsubstitutedquaternaryammoniumalkylcarboxy, a substituted or unsubstituteddi(alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—, H₂N—HC(Q₅)-C(O)—N(H)—,substituted or unsubstituted azidoalkyloxy, substituted or unsubstitutedcyanoalkyloxy, P.G.-HN—HC(Q₅)-C(O)—O—, substituted or unsubstitutedguanidinoalkyloxy, and a substituted or unsubstitutedguanidinoalkylcarboxy.

In some embodiments, R₁ through R₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, and R₁₈are independently selected from the group consisting of hydrogen,hydroxyl, a substituted or unsubstituted (C₁-C₁₈) alkyl, substituted orunsubstituted (C₁-C₁₈) hydroxyalkyl, substituted or unsubstituted(C₁-C₁₈) alkyloxy-(C₁-C₁₈) alkyl, substituted or unsubstituted (C₁-C₁₈)alkylcarboxy-(C₁-C₁₈) alkyl, substituted or unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈)alkyl, substituted or unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino, substituted or unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, a substituted orunsubstituted (C₁-C₁₈) aminoalkyl, a substituted or unsubstituted aryl,a substituted or unsubstituted arylamino-(C₁-C₁₈) alkyl, substituted orunsubstituted (C₁-C₁₈) haloalkyl, substituted or unsubstituted (C₂-C₆)alkenyl, substituted or unsubstituted (C₂-C₆) alkynyl, oxo, a linkinggroup attached to a second steroid, a substituted or unsubstituted(C₁-C₁₈) aminoalkyloxy, a substituted or unsubstituted (C₁-C₁₈)aminoalkyloxy-(C₁-C₁₈) alkyl, a substituted or unsubstituted (C₁-C₁₈)aminoalkylcarboxy, a substituted or unsubstituted (C₁-C₁₈)aminoalkylaminocarbonyl, a substituted or unsubstituted (C₁-C₁₈)aminoalkylcarboxamido, a substituted or unsubstituted di(C₁-C₁₈alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—, H₂N—HC(Q₅)-C(O)—N(H)—, substitutedor unsubstituted (C₁-C₁₈) azidoalkyloxy, substituted or unsubstituted(C₁-C₁₈) cyanoalkyloxy, P.G.-HN—HC(Q₅)-C(O)—O—, substituted orunsubstituted (C₁-C₁₈) guanidinoalkyloxy, substituted or unsubstituted(C₁-C₁₈) quaternaryammoniumalkylcarboxy, and substituted orunsubstituted (C₁-C₁₈) guanidinoalkyl carboxy, where Q₅ is a side chainof any amino acid (including a side chain of glycine, i.e., H), and P.G.is an amino protecting group; and R₅, R₈, R₉, R₁₀, R₁₃, R₁₄ and R₁₇ areindependently deleted when one of rings A, B, C, or D is unsaturated soas to complete the valency of the carbon atom at that site, or R₅, R₈,R₉, R₁₀, R₁₃, and R₁₄ are independently selected from the groupconsisting of hydrogen, hydroxyl, a substituted or unsubstituted(C₁-C₁₈) alkyl, substituted or unsubstituted (C₁-C₁₈) hydroxyalkyl,substituted or unsubstituted (C₁-C₁₈) alkyloxy-(C₁-C₁₈) alkyl, asubstituted or unsubstituted (C₁-C₁₈) aminoalkyl, a substituted orunsubstituted aryl, substituted or unsubstituted (C₁-C₁₈) haloalkyl,substituted or unsubstituted (C₂-C₆) alkenyl, substituted orunsubstituted (C₂-C₆) alkynyl, oxo, a linking group attached to a secondsteroid, a substituted or unsubstituted (C₁-C₁₈) aminoalkyloxy, asubstituted or unsubstituted (C₁-C₁₈) aminoalkylcarboxy, a substitutedor unsubstituted (C₁-C₁₈) aminoalkylaminocarbonyl, di(C₁-C₁₈alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—, H₂N—HC(Q₅)-C(O)—N(H)—, substitutedor unsubstituted (C₁-C₁₈) azidoalkyloxy, substituted or unsubstituted(C₁-C₁₈) cyanoalkyloxy, P.G.-HN—HC(Q₅)-C(O)—O—, substituted orunsubstituted (C₁-C₁₈) guanidinoalkyloxy, and substituted orunsubstituted (C₁-C₁₈) guanidinoalkylcarboxy, where Q₅ is a side chainof any amino acid, and P.G. is an amino protecting group; provided thatat least two or three of R₁₋₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, R₁₇, and R₁₈are independently selected from the group consisting of a substituted orunsubstituted (C₁-C₁₈) aminoalkyl, a substituted or unsubstituted(C₁-C₁₈) aminoalkyloxy, substituted or unsubstituted (C₁-C₁₈)alkylcarboxy-(C₁-C₁₈) alkyl, substituted or unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino, substituted or unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino (C₁-C₁₈) alkylamino, a substituted orunsubstituted (C₁-C₁₈) aminoalkylcarboxy, a substituted or unsubstitutedarylamino (C₁-C₁₈) alkyl, a substituted or unsubstituted (C₁-C₁₈)aminoalkyloxy (C₁-C₁₈) aminoalkylaminocarbonyl, a substituted orunsubstituted (C₁-C₁₈) aminoalkylaminocarbonyl, a substituted orunsubstituted (C₁-C₁₈) aminoalkylcarboxyamido, a substituted orunsubstituted (C₁-C₁₈) quaternaryammoniumalkylcarboxy, substituted orunsubstituted di(C₁-C₁₈ alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—,H₂N—HC(Q₅)-C(O)—N(H)—, substituted or unsubstituted (C₁-C₁₈)azidoalkyloxy, substituted or unsubstituted (C₁-C₁₈) cyanoalkyloxy,P.G.-HN—HC(Q₅)-C(O)—O—, substituted or unsubstituted (C₁-C₁₈)guanidinoalkyloxy, and a substituted or unsubstituted (C₁-C₁₈)guanidinoalkylcarboxy.

In some embodiments, R₁ through R₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, and R₁₈are independently selected from the group consisting of hydrogen,hydroxyl, an unsubstituted (C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈)hydroxyalkyl, unsubstituted (C₁-C₁₈) alkyloxy-(C₁-C₁₈) alkyl,unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈) alkyl, unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted(C₁-C₁₈) aminoalkyl, an unsubstituted aryl, an unsubstitutedarylamino-(C₁-C₁₈) alkyl, oxo, an unsubstituted (C₁-C₁₈) aminoalkyloxy,an unsubstituted (C₁-C₁₈) aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted(C₁-C₁₈) aminoalkylcarboxy, an unsubstituted (C₁-C₁₈)aminoalkylaminocarbonyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈ alkyl)aminoalkyl,unsubstituted (C₁-C₁₈) guanidinoalkyloxy, unsubstituted (C₁-C₁₈)quaternaryammoniumalkylcarboxy, and unsubstituted (C₁-C₁₈)guanidinoalkyl carboxy; and R₅, R₈, R₉, R₁₀, R₁₃, R₁₄ and R₁₇ areindependently deleted when one of rings A, B, C, or D is unsaturated soas to complete the valency of the carbon atom at that site, or R₅, R₈,R₉, R₁₀, R₁₃, and R₁₄ are independently selected from the groupconsisting of hydrogen, hydroxyl, an unsubstituted (C₁-C₁₈) alkyl,unsubstituted (C₁-C₁₈) hydroxyalkyl, unsubstituted (C₁-C₁₈)alkyloxy-(C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈) alkylamino-(C₁-C₁₈)alkyl, unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted(C₁-C₁₈) aminoalkyl, an unsubstituted aryl, an unsubstitutedarylamino-(C₁-C₁₈) alkyl, oxo, an unsubstituted (C₁-C₁₈) aminoalkyloxy,an unsubstituted (C₁-C₁₈) aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted(C₁-C₁₈) aminoalkylcarboxy, an unsubstituted (C₁-C₁₈)aminoalkylaminocarbonyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈ alkyl)aminoalkyl,unsubstituted (C₁-C₁₈) guanidinoalkyloxy, unsubstituted (C₁-C₁₈)quaternaryammoniumalkylcarboxy, and unsubstituted (C₁-C₁₈)guanidinoalkyl carboxy; provided that at least two or three of R₁₋₄, R₆,R₇, R₁₁, R₁₂, R₁₅, R₁₆, R₁₇, and R₁₈ are independently selected from thegroup consisting of of hydrogen, hydroxyl, an unsubstituted (C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈) hydroxyalkyl, unsubstituted (C₁-C₁₈)alkyloxy-(C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈) alkylamino-(C₁-C₁₈)alkyl, unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted(C₁-C₁₈) aminoalkyl, an unsubstituted aryl, an unsubstitutedarylamino-(C₁-C₁₈) alkyl, oxo, an unsubstituted (C₁-C₁₈) aminoalkyloxy,an unsubstituted (C₁-C₁₈) aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted(C₁-C₁₈) aminoalkylcarboxy, an unsubstituted (C₁-C₁₈)aminoalkylaminocarbonyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈ alkyl)aminoalkyl,unsubstituted (C₁-C₁₈) guanidinoalkyloxy, unsubstituted (C₁-C₁₈)quaternaryammoniumalkylcarboxy, and unsubstituted (C₁-C₁₈)guanidinoalkyl carboxy.

In some embodiments, the CSA, or pharmaceutically acceptable saltsthereof of Formula (I), is represented by Formula (II):

In some embodiments, rings A, B, C, and D are independently saturated.

In some embodiments, one or more of rings A, B, C, and D areheterocyclic.

In some embodiments, rings A, B, C, and D are non-heterocyclic.

In some embodiments, R₃, R₇, R₁₂, and R₁₈ are independently selectedfrom the group consisting of hydrogen, an unsubstituted (C₁-C₁₈) alkyl,unsubstituted (C₁-C₁₈) hydroxyalkyl, unsubstituted (C₁-C₁₈)alkyloxy-(C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈) alkylamino-(C₁-C₁₈)alkyl, unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted(C₁-C₁₈) aminoalkyl, an unsubstituted arylamino-(C₁-C₁₈) alkyl, anunsubstituted (C₁-C₁₈) aminoalkyloxy, an unsubstituted (C₁-C₁₈)aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxy, an unsubstituted (C₁-C₁₈) aminoalkylaminocarbonyl, anunsubstituted (C₁-C₁₈) aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈alkyl)aminoalkyl, unsubstituted (C₁-C₁₈) guanidinoalkyloxy,unsubstituted (C₁-C₁₈) quaternaryammoniumalkylcarboxy, and unsubstituted(C₁-C₁₈) guanidinoalkyl carboxy; and R₁, R₂, R₄, R₅, R₆, R₈, R₉, R₁₀,R₁₁, R₁₃, R₁₄, R₁₅, R₁₆, and R₁₇ are independently selected from thegroup consisting of hydrogen and unsubstituted (C₁-C₆) alkyl.

In some embodiments, R₃, R₇, R₁₂, and R₁₈ are independently selectedfrom the group consisting of hydrogen, an unsubstituted (C₁-C₆) alkyl,unsubstituted (C₁-C₆) hydroxyalkyl, unsubstituted (C₁-C₁₆)alkyloxy-(C₁-C₅) alkyl, unsubstituted (C₁-C₁₆) alkylcarboxy-(C₁-C₅)alkyl, unsubstituted (C₁-C₁₆) alkylamino-(C₁-C₅)alkyl, unsubstituted(C₁-C₁₆) alkylamino-(C₁-C₅) alkylamino, unsubstituted (C₁-C₁₆)alkylamino-(C₁-C₁₆) alkylamino-(C₁-C₅) alkylamino, an unsubstituted(C₁-C₁₆) aminoalkyl, an unsubstituted arylamino-(C₁-C₅) alkyl, anunsubstituted (C₁-C₅) aminoalkyloxy, an unsubstituted (C₁-C₁₆)aminoalkyloxy-(C₁-C₅) alkyl, an unsubstituted (C₁-C₅) aminoalkylcarboxy,an unsubstituted (C₁-C₅) aminoalkylaminocarbonyl, an unsubstituted(C₁-C₅) aminoalkylcarboxamido, an unsubstituted di(C₁-C₅alkyl)amino-(C₁-C₅) alkyl, unsubstituted (C₁-C₅) guanidinoalkyloxy,unsubstituted (C₁-C₁₆) quaternaryammoniumalkylcarboxy, and unsubstituted(C₁-C₁₆) guanidinoalkylcarboxy.

In some embodiments, R₁, R₂, R₄, R₅, R₆, R₈, R₁₀, R₁₁, R₁₄, R₁₆, and R₁₇are each hydrogen; and R₉ and R₁₃ are each methyl.

In some embodiments, R₃, R₇, R₁₂, and R₁₈ are independently selectedfrom the group consisting of aminoalkyloxy; aminoalkylcarboxy;alkylaminoalkyl; alkoxycarbonylalkyl; alkylcarbonylalkyl;di(alkyl)aminoalkyl; alkoxycarbonylalkyl; and alkylcarboxyalkyl.

In some embodiments, R₃, R₇, and R₁₂ are independently selected from thegroup consisting of aminoalkyloxy and aminoalkylcarboxy; and R₁₈ isselected from the group consisting of alkylaminoalkyl;alkoxycarbonylalkyl; alkylcarbonyloxyalkyl; di(alkyl)aminoalkyl;alkylaminoalkyl; alkyoxycarbonylalkyl; and alkylcarboxyalkyl.

In some embodiments, R₃, R₇, and R₁₂ are the same.

In some embodiments, R₃, R₇, and R₁₂ are aminoalkyloxy.

In some embodiments, R₃, R₇, and R₁₂ are aminoalkylcarboxy.

In some embodiments, R₁₈ is alkylaminoalkyl.

In some embodiments, R₁₈ is alkoxycarbonylalkyl.

In some embodiments, R₁₈ is di(alkyl)aminoalkyl.

In some embodiments, R₁₈ is alkylcarboxyalkyl.

In some embodiments, R₃, R₇, R₁₂, and R₁₈ are independently selectedfrom the group consisting of amino-C₃-alkyloxy; amino-C₃-alkyl-carboxy;C₈-alkylamino-C₅-alkyl; C₈-alkoxy-carbonyl-C₄-alkyl;C₈-alkyl-carbonyl-C₄-alkyl; di-(C₅-alkyl)amino-C₅-alkyl;C₁₃-alkylamino-C₅-alkyl; C₆-alkoxy-carbonyl-C₄-alkyl;C₆-alkyl-carboxy-C₄-alkyl; and C₁₆-alkylamino-C₅-alkyl.

In some embodiments, m, n, and p are each 1 and q is 0.

In some embodiments, the CSA, or pharmaceutically acceptable saltsthereof of Formula (I) is represented by Formula (III):

In some embodiments, the CSA, or a pharmaceutically acceptable saltthereof, is:

In some embodiments, the CSA, or a pharmaceutically acceptable saltthereof, is

In other embodiments, the CSA, or a pharmaceutically acceptable saltthereof, is

In other embodiments, the CSA, or a pharmaceutically acceptable saltthereof, is

In other embodiments, the CSA, or a pharmaceutically acceptable saltthereof, is

Some embodiments are CSA compositions comprising at least one CSA andone or more poloxymers. In some embodiments, the compositions furthercomprise albumin. In some embodiments, the composition contains lessthan about 20% by weight of CSA; and between about 10% to about 40% byweight of one or more poloxymer or between about 20% to about 30% byweight of one or more poloxymers. In some embodiments, the ratio of theone or more poloxamers to CSA is between about 30 to 1 to about 3 to 1.In some embodiments, the one or more poloxamers has a molecular weightof about 3600 g/mol for the central hydrophobic chain ofpolyoxypropylene and has about 70% polyoxyethylene content.

In some embodiments, the CSA prevents, inhibits, or reduces the symptomsassociated with a disease or symptom selected from oral mucositis,gingivitis, periodontitis, gastric mucositis, inflammatory fibrosis,gastritis, colitis, ileitis, Crohn's disease, chronic inflammatoryintestinal disease, inflammatory bowel syndrome, chronic inflammatorybowel disease, celiac disease, ulcerative colitis, a gastric ulcer, apeptic ulcer, a buccal ulcer, a nasopharyngeal ulcer, an esophagealulcer, a duodenal ulcer, a gastrointestinal ulcer, an autoimmunedisorder, pain, or pain associated with one or more of said diseases.For example, in some embodiments, the CSA inhibits inflammationassociated with the aforementioned diseases.

In some embodiments, the CSA inhibits inflammation mediated by a tumornecrosis factor. In some embodiments, the CSA inhibits, reduces, orprevents inflammation of the periodontal ligament or the alveolar bone.In other embodiments, the CSA inhibits, reduces, or prevents resorptionof alveolar bone. In some embodiments, the CSA inhibits, reduces, orprevents the episodic resorption of alveolar bone. In other embodiments,the CSA inhibits, reduces, or prevents the continuous resorption ofalveolar bone. In some embodiments, the CSA promotes the regeneration ofalveolar bone, periodontal ligament, or root cementum. In someembodiments, the CSA inhibits, reduces, or prevents pain caused by oralmucositis, gingivitis, periodontitis, gastric mucositis, inflammatoryfibrosis, gastritis, colitis, ileitis, Crohn's disease, chronicinflammatory intestinal disease, inflammatory bowel syndrome, chronicinflammatory bowel disease, celiac disease, ulcerative colitis, agastric ulcer, a peptic ulcer, a buccal ulcer, a nasopharyngeal ulcer,an esophageal ulcer, a duodenal ulcer, an autoimmune disorder, and agastrointestinal ulcer. In some embodiments, the CSA inhibits, reduces,or prevents pain.

In some embodiments, the therapeutic effect of the CSA is derived fromits steroid-like structure. In other embodiments, the therapeutic effectof the CSA is derived from its antibiotic activity. In some embodiments,the therapeutic effect of the CSA is derived from a combination ofantibiotic and anti-inflammatory activity. In other embodiments, thetherapeutic effect of the CSA is derived from a combination ofantibiotic and anti-pain activity. In some embodiments, the therapeuticeffect of the CSA is derived from a combination of anti-inflammatory andanti-pain activity.

In some embodiments, the therapeutic effect of the CSA is derived from amodulation of IL-1A. In some embodiments, the therapeutic effect of theCSA is derived from a modulation of IL-1B. In some embodiments, thetherapeutic effect of the CSA is derived from a modulation of TLR2. Insome embodiments, the therapeutic effect of the CSA is derived from amodulation of TLR4. In some embodiments, the therapeutic effect of theCSA is derived from a modulation of TLR6. In some embodiments, thetherapeutic effect of the CSA is derived from a modulation of TLR8. Insome embodiments, the therapeutic effect of the CSA is derived from amodulation of TLR9.

In some embodiments, the therapeutic effect of the CSA is derived from amodulation of TNFRSF1A. In some embodiments, the therapeutic effect ofthe CSA is derived from a modulation of TNF. In some embodiments, thetherapeutic effect of the CSA is derived from a modulation ofTNF-beta 1. In some embodiments, the therapeutic effect of the CSA isderived from a modulation of CCL2. In some embodiments, the therapeuticeffect of the CSA is derived from a modulation of CXCR4. In someembodiments, the therapeutic effect of the CSA is derived from amodulation of IRAK2. In some embodiments, the therapeutic effect of theCSA is derived from a modulation of miR-29d.

In some embodiments, the therapeutic effect of the CSA is derived from amodulation of NFKB1. In some embodiments, the therapeutic effect of theCSA is derived from a modulation of NFKB2. In some embodiments, thetherapeutic effect of the CSA is derived from a modulation of NFKB1A. Insome embodiments, the therapeutic effect of the CSA is derived from amodulation of NFKB. In some embodiments, the therapeutic effect of theCSA is derived from a modulation of IL-6. In one embodiment, CSA isadministered to reduce an inflammatory response in cystic fibrosispatients, including but not limited to an inflammatory responsecharacterized by increased IL-6 levels. (For correlation between cysticfibrosis and IL-6 levels, see, e.g., Paats, et al., J. Cyst. Fibros.2013 Jun. 7 p. 51569-1993(13)00078-7.)

Pharmaceutically Acceptable Salts

The compounds and compositions disclosed herein are optionally preparedas pharmaceutically acceptable salts. The term “pharmaceuticallyacceptable salt” as used herein is a broad term, and is to be given itsordinary and customary meaning to a skilled artisan (and is not to belimited to a special or customized meaning), and refers withoutlimitation to a salt of a compound that does not cause significantirritation to an organism to which it is administered and does notabrogate the biological activity and properties of the compound. In someembodiments, the salt is an acid addition salt of the compound.Pharmaceutical salts can be obtained by reacting a compound withinorganic acids such as hydrohalic acid (e.g., hydrochloric acid orhydrobromic acid), sulfuric acid, nitric acid, and phosphoric acid.Pharmaceutical salts can also be obtained by reacting a compound with anorganic acid such as aliphatic or aromatic carboxylic or sulfonic acids,for example formic acid, acetic acid, propionic acid, glycolic acid,pyruvic acid, malonic acid, maleic acid, fumaric acid, trifluoroaceticacid, benzoic acid, cinnamic acid, mandelic acid, succinic acid, lacticacid, malic acid, tartaric acid, citric acid, ascorbic acid, nicotinicacid, methanesulfonic acid, ethanesulfonic acid, p-toluensulfonic acid,salicylic acid, stearic acid, muconic acid, butyric acid, phenylaceticacid, phenylbutyric acid, valproic acid, 1,2-ethanedisulfonic acid,2-hydroxyethanesulfonic acid, benzenesulfonic acid,2-naphthalenesulfonic acid, or naphthalenesulfonic acid. Pharmaceuticalsalts can also be obtained by reacting a compound with a base to form asalt such as an ammonium salt, an alkali metal salt, such as a lithium,sodium or a potassium salt, an alkaline earth metal salt, such as acalcium, magnesium or aluminum salt, a salt of organic bases such asdicyclohexylamine, N-methyl-D-glucamine, tris(hydroxymethyl)methylamine,C₁-C₇ alkylamine, cyclohexylamine, dicyclohexylamine, triethanolamine,ethylenediamine, ethanolamine, diethanolamine, triethanolamine,tromethamine, and salts with amino acids such as arginine and lysine; ora salt of an inorganic base, such as aluminum hydroxide, calciumhydroxide, potassium hydroxide, sodium carbonate, sodium hydroxide, orthe like.

In some embodiments, the pharmaceutically acceptable salt is ahydrochloride salt. In some embodiments, the pharmaceutically acceptablesalt is a mono-hydrochloride salt, a di-hydrochloride salt, atri-hydrochloride salt, or a tetra-hydrochloride salt.

Co-Administration:

As used herein, “co-administration” means concurrently or administeringone substance followed by beginning the administration of a secondsubstance within 24 hours, 20 hours, 16 hours, 12 hours, 8 hours, 4hours, 1 hour, 30 minutes, 15 minutes, 5 minutes, 1 minute, a rangebounded by any two of the aforementioned numbers, and/or about any ofthe aforementioned numbers.

In some embodiments, one or more CSAs are co-administered. In otherembodiments, the co-administration of CSAs accounts for theirtherapeutic benefit. In some embodiments, co-administration isconcurrent.

In some embodiments, one or more CSAs having antibiotic activity areadministered to the patient. In some embodiments, a single CSA isadministered and responsible for both antibiotic activity and activityfor treating any one or more of pain, oral mucositis, gingivitis,periodontitis, gastric mucositis, gastritis, colitis, ileitis, Crohn'sdisease, chronic inflammatory intestinal disease, inflammatory bowelsyndrome, chronic inflammatory bowel disease, celiac disease, cysticfibrosis, ulcerative colitis, a gastric ulcer, a peptic ulcer, a buccalulcer, a nasopharyngeal ulcer, an esophageal ulcer, a duodenal ulcer, anautoimmune disorder, and/or a gastrointestinal ulcer, and/or painassociated with any of the aforementioned diseases. In some embodiments,the one or more CSAs having antibiotic activity are co-administered tothe patient. In other embodiments, a non-CSA antibiotic is administeredto the patient. In other embodiments, a non-CSA antibiotic isco-administered to the patient. Such agents include, but are not limitedto, a regulatory agency approved antibiotic. In some embodiments, theregulatory agency is the Food and Drug Administration (FDA). In otherembodiments, the antibiotic is an aminoglycoside, an ansamycin, acarbacephem, a carbapenem, a cephalosporin, a glycopeptide, alincosamide, a lipopeptide, a macrolide, a monbactam, a nitrofuran, anoxazolidonone, a penicillin, a polypeptide, a quinolone, a sulfonamide,or a tetracycline.

In some embodiments, one or more non-CSA anti-inflammatory agents areadministered to the patient. In some embodiments, the one or morenon-CSA anti-inflammatory agents are co-administered. Such agentsinclude, but are not limited to, a regulatory agency approvedanti-inflammatory agent. In some embodiments, the regulatory agency isthe Food and Drug Administration (FDA). In other embodiments, theanti-inflammatory agent is a non-steroidal anti-inflammatory agent(“NSAID”) such as aspirin, diclofenac, ibuprogen, naproxen, rofecoxib,and the like. In some embodiments, acetaminophen is administered withthe CSA. In other embodiments, the anti-inflammatory agent is asteroidal anti-inflammatory agent such as prednisone or prednisolone.

In some embodiments, the CSA is useful for treating pain associated withsaid disease state. Additional pain relievers are administered orco-administered to a patient in need thereof in certain embodiments.Such pain relievers include, but are not limited to, a regulatory agencyapproved pain reliever. In some embodiments, the regulatory agency isthe Food and Drug Administration (FDA). Pain relievers are well known inthe art and include the above mentioned NSAIDS and steroids, as well asacetaminophen, opioids, and the like.

Formulations

While it is possible for the compounds described herein to beadministered alone, it may be preferable to formulate the compounds aspharmaceutical compositions (i.e., formulations). As such, in yetanother aspect, pharmaceutical compositions useful in the methods anduses of the disclosed embodiments are provided. More particularly, thepharmaceutical compositions described herein may be useful, inter alia,for treating, reducing, or preventing a disease or symptom selected fromoral mucositis, gingivitis, periodontitis, gastric mucositis, gastritis,colitis, ileitis, Crohn's disease, chronic inflammatory intestinaldisease, inflammatory bowel syndrome, chronic inflammatory boweldisease, celiac disease, ulcerative colitis, a gastric ulcer, a pepticulcer, a buccal ulcer, a nasopharyngeal ulcer, an esophageal ulcer, aduodenal ulcer or a gastrointestinal ulcer, an autoimmune disorder,pain, and/or pain associated with said diseases. A pharmaceuticalcomposition is any composition that may be administered in vitro or invivo or both to a subject in order to treat or ameliorate a condition.In a preferred embodiment, a pharmaceutical composition may beadministered in vivo. A subject may include one or more cells ortissues, or organisms. In some exemplary embodiments, the subject is ananimal. In some embodiments, the animal is a mammal. The mammal may be ahuman or primate in some embodiments. A mammal includes any mammal, suchas by way of non-limiting example, cattle, pigs, sheep, goats, horses,camels, buffalo, cats, dogs, rats, mice, and humans.

As used herein the terms “pharmaceutically acceptable” and“physiologically acceptable” mean a biologically compatible formulation,gaseous, liquid or solid, or mixture thereof, which is suitable for oneor more routes of administration, in vivo delivery, or contact. Aformulation is compatible in that it does not destroy activity of anactive ingredient therein (e.g., a CSA), or induce adverse side effectsthat far outweigh any prophylactic or therapeutic effect or benefit.

In an embodiment, the pharmaceutical compositions may be formulated withpharmaceutically acceptable excipients such as carriers, solvents,stabilizers, adjuvants, diluents, etc., depending upon the particularmode of administration and dosage form. The pharmaceutical compositionsshould generally be formulated to achieve a physiologically compatiblepH, and may range from a pH of about 3 to a pH of about 11, preferablyabout pH 3 to about pH 7, depending on the formulation and route ofadministration. In alternative embodiments, it may be preferred that thepH is adjusted to a range from about pH 5.0 to about pH 8. Moreparticularly, the pharmaceutical compositions may comprise atherapeutically or prophylactically effective amount of at least onecompound as described herein, together with one or more pharmaceuticallyacceptable excipients. Optionally, the pharmaceutical compositions maycomprise a combination of the compounds described herein, or may includea second active ingredient useful in the treatment or prevention ofbacterial infection (e.g., anti-bacterial or anti-microbial agents).

Formulations, e.g., for parenteral or oral administration, are mosttypically solids, liquid solutions, emulsions or suspensions, whileinhalable formulations for pulmonary administration are generallyliquids or powders, with powder formulations being generally preferred.A preferred pharmaceutical composition may also be formulated as alyophilized solid that is reconstituted with a physiologicallycompatible solvent prior to administration. Alternative pharmaceuticalcompositions may be formulated as syrups, creams, ointments, tablets,and the like.

Compositions may contain one or more excipients. Pharmaceuticallyacceptable excipients are determined in part by the particularcomposition being administered, as well as by the particular method usedto administer the composition. Accordingly, there exists a wide varietyof suitable formulations of pharmaceutical compositions (see, e.g.,Remington's Pharmaceutical Sciences).

Suitable excipients may be carrier molecules that include large, slowlymetabolized macromolecules such as proteins, polysaccharides, polylacticacids, polyglycolic acids, polymeric amino acids, amino acid copolymers,and inactive virus particles. Other exemplary excipients includeantioxidants such as ascorbic acid; chelating agents such as EDTA;carbohydrates such as dextrin, hydroxyalkylcellulose,hydroxyalkylmethylcellulose, stearic acid; liquids such as oils, water,saline, glycerol and ethanol; wetting or emulsifying agents; pHbuffering substances; and the like. Liposomes are also included withinthe definition of pharmaceutically acceptable excipients.

The pharmaceutical compositions described herein may be formulated inany form suitable for the intended method of administration. Whenintended for oral use for example, tablets, troches, lozenges, aqueousor oil suspensions, non-aqueous solutions, dispersible powders orgranules (including micronized particles or nanoparticles), emulsions,hard or soft capsules, syrups or elixirs may be prepared. Compositionsintended for oral use may be prepared according to any method known tothe art for the manufacture of pharmaceutical compositions, and suchcompositions may contain one or more agents including sweetening agents,flavoring agents, coloring agents and preserving agents, in order toprovide a palatable preparation.

Pharmaceutically acceptable excipients particularly suitable for use inconjunction with tablets include, for example, inert diluents, such ascelluloses, calcium or sodium carbonate, lactose, calcium or sodiumphosphate; disintegrating agents, such as cross-linked povidone, maizestarch, or alginic acid; binding agents, such as povidone, starch,gelatin or acacia; and lubricating agents, such as magnesium stearate,stearic acid or talc.

Tablets may be uncoated or may be coated by known techniques includingmicroencapsulation to delay disintegration and adsorption in thegastrointestinal tract and thereby provide a sustained action over alonger period. For example, a time delay material such as glycerylmonostearate or glyceryl distearate alone or with a wax may be employed.

Formulations for oral use may be also presented as hard gelatin capsuleswhere the active ingredient is mixed with an inert solid diluent, forexample celluloses, lactose, calcium phosphate or kaolin, or as softgelatin capsules wherein the active ingredient is mixed with non-aqueousor oil medium, such as glycerin, propylene glycol, polyethylene glycol,peanut oil, liquid paraffin or olive oil.

In another embodiment, pharmaceutical compositions may be formulated assuspensions comprising a compound of the embodiments in admixture withat least one pharmaceutically acceptable excipient suitable for themanufacture of a suspension.

In yet another embodiment, pharmaceutical compositions may be formulatedas dispersible powders and granules suitable for preparation of asuspension by the addition of suitable excipients.

Excipients suitable for use in connection with suspensions includesuspending agents, such as sodium carboxymethylcellulose,methylcellulose, hydroxypropyl methylcellulose, sodium alginate,polyvinylpyrrolidone, gum tragacanth, gum acacia, dispersing or wettingagents such as a naturally occurring phosphatide (e.g., lecithin), acondensation product of an alkylene oxide with a fatty acid (e.g.,polyoxyethylene stearate), a condensation product of ethylene oxide witha long chain aliphatic alcohol (e.g., heptadecaethyleneoxycethanol), acondensation product of ethylene oxide with a partial ester derived froma fatty acid and a hexitol anhydride (e.g., polyoxyethylene sorbitanmonooleate); polysaccharides and polysaccharide-like compounds (e.g.dextran sulfate); glycoaminoglycans and glycosaminoglycan-like compounds(e.g., hyaluronic acid); and thickening agents, such as carbomer,beeswax, hard paraffin or cetyl alcohol. The suspensions may alsocontain one or more preservatives such as acetic acid, methyl and/orn-propyl p-hydroxy-benzoate; one or more coloring agents; one or moreflavoring agents; and one or more sweetening agents such as sucrose orsaccharin.

The pharmaceutical compositions may also be in the form of oil-in wateremulsions. The oily phase may be a vegetable oil, such as olive oil orarachis oil, a mineral oil, such as liquid paraffin, or a mixture ofthese. Suitable emulsifying agents include naturally-occurring gums,such as gum acacia and gum tragacanth; naturally occurring phosphatides,such as soybean lecithin, esters or partial esters derived from fattyacids; hexitol anhydrides, such as sorbitan monooleate; and condensationproducts of these partial esters with ethylene oxide, such aspolyoxyethylene sorbitan monooleate. The emulsion may also containsweetening and flavoring agents. Syrups and elixirs may be formulatedwith sweetening agents, such as glycerol, sorbitol or sucrose. Suchformulations may also contain a demulcent, a preservative, a flavoringor a coloring agent.

Additionally, the pharmaceutical compositions may be in the form of asterile injectable preparation, such as a sterile injectable aqueousemulsion or oleaginous suspension. This emulsion or suspension may beformulated according to the known art using those suitable dispersing orwetting agents and suspending agents which have been mentioned above.The sterile injectable preparation may also be a sterile injectablesolution or suspension in a non-toxic parenterally acceptable diluent orsolvent, such as a solution in 1,2-propane-diol.

The sterile injectable preparation may also be prepared as a lyophilizedpowder. Among the acceptable vehicles and solvents that may be employedare water, Ringer's solution, and isotonic sodium chloride solution. Inaddition, sterile fixed oils may be employed as a solvent or suspendingmedium. For this purpose any bland fixed oil may be employed includingsynthetic mono- or diglycerides. In addition, fatty acids such as oleicacid may likewise be used in the preparation of injectables.

To obtain a stable water-soluble dose form of a pharmaceuticalcomposition, a pharmaceutically acceptable salt of a compound describedherein may be dissolved in an aqueous solution of an organic orinorganic acid, such as 0.3 M solution of succinic acid, or morepreferably, citric acid. If a soluble salt form is not available, thecompound may be dissolved in a suitable co-solvent or combination ofco-solvents. Examples of suitable co-solvents include alcohol, propyleneglycol, polyethylene glycol 300, polysorbate 80, glycerin and the likein concentrations ranging from about 0 to about 60% of the total volume.In one embodiment, the active compound is dissolved in DMSO and dilutedwith water.

The pharmaceutical composition may also be in the form of a solution ofa salt form of the active ingredient in an appropriate aqueous vehicle,such as water or isotonic saline or dextrose solution. Also contemplatedare compounds which have been modified by substitutions or additions ofchemical or biochemical moieties which make them more suitable fordelivery (e.g., increase solubility, bioactivity, palatability, decreaseadverse reactions, etc.), for example by esterification, glycosylation,PEGylation, and complexation.

Many therapeutics have undesirably short half-lives and/or undesirabletoxicity. Thus, the concept of improving half-life or toxicity isapplicable to various treatments and fields. Pharmaceutical compositionscan be prepared, however, by complexing the therapeutic with abiochemical moiety to improve such undesirable properties. Proteins area particular biochemical moiety that may be complexed with a CSA foradministration in a wide variety of applications. In some embodiments,one or more CSAs are complexed with a protein for the treatment ofinfection. In other embodiments, one or more CSAs are complexed with aprotein for the treatment, reduction, or inhibition of a disease orsymptom selected from oral mucositis, gingivitis, periodontitis, gastricmucositis, gastritis, colitis, ileitis, Crohn's disease, chronicinflammatory intestinal disease, inflammatory bowel syndrome, chronicinflammatory bowel disease, celiac disease, ulcerative colitis, agastric ulcer, a peptic ulcer, a buccal ulcer, a nasopharyngeal ulcer,an esophageal ulcer, a duodenal ulcer or a gastrointestinal ulcer, pain,and/or pain associated with said diseases. In some embodiments, one ormore CSAs are complexed with a protein to increase the CSA's half-life.In other embodiments, one or more CSAs are complexed with a protein todecrease the CSA's toxicity. Albumin is a particularly preferred proteinfor complexation with a CSA. In some embodiments, the albumin isfat-free albumin.

With respect to the CSA therapeutic, the biochemical moiety forcomplexation can be added to the pharmaceutical composition as 0.25,0.5, 0.75, 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 10, 20, 50, or 100 weightequivalents, or a range bounded by any two of the aforementionednumbers, or about any of the numbers. In some embodiments, the weightratio of albumin to CSA is about 18:1 or less, such as about 9:1 orless. In some embodiments, the CSA is coated with albumin.

Alternatively, or in addition, non-biochemical compounds can be added tothe pharmaceutical compositions to reduce the toxicity of thetherapeutic and/or improve the half-life. Suitable amounts and ratios ofan additive that can reduce toxicity can be determined via a cellularassay. With respect to the CSA therapeutic, toxicity reducing compoundscan be added to the pharmaceutical composition as 0.25, 0.5, 0.75, 1,1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 10, 20, 50, or 100 weight equivalents,or a range bounded by any two of the aforementioned numbers, or aboutany of the numbers. In some embodiments, the toxicity reducing compoundis a cocoamphodiacetate such as Miranol® (disodium cocoamphodiacetate).In other embodiments, the toxicity reducing compound is an amphotericsurfactant. In some embodiments, the toxicity reducing compound is asurfactant. In other embodiments, the molar ratio of cocoamphodiacetateto CSA is between about 8:1 and 1:1, preferably about 4:1. In someembodiments, the toxicity reducing compound is allantoin.

In some embodiments, a CSA composition is prepared utilizing one or moresurfactants. In specific embodiments, the CSA is complexed with one ormore poloxamer surfactants. Poloxamer surfactants are nonionic triblockcopolymers composed of a central hydrophobic chain of polyoxypropylene(poly(propylene oxide)) flanked by two hydrophilic chains ofpolyoxyethylene (poly(ethylene oxide)). In some embodiments, thepoloxamer is a liquid, paste, or flake (solid). Examples of suitablepoloxamers include those by the trade names Synperonics, Pluronics, orKolliphor. In some embodiments, one or more of the poloxamer surfactantin the composition is a flake poloxamer. In some embodiments, the one ormore poloxamer surfactant in the composition has a molecular weight ofabout 3600 g/mol for the central hydrophobic chain of polyoxypropyleneand has about 70% polyoxyethylene content. In some embodiments, theratio of the one or more poloxamer to CSA is between about 50 to 1;about 40 to 1; about 30 to 1; about 20 to 1; about 10 to 1; about 5 to1; about 1 to 1; about 1 to 10; about 1 to 20; about 1 to 30; about 1 to40; or about 1 to 50. In other embodiments, the ratio of the one or morepoloxamer to CSA is between 50 to 1; 40 to 1; 30 to 1; 20 to 1; 10 to 1;5 to 1; 1 to 1; 1 to 10; 1 to 20; 1 to 30; 1 to 40; or 1 to 50. In someembodiments, the ratio of the one or more poloxamer to CSA is betweenabout 50 to 1 to about 1 to 50. In other embodiments, the ratio of theone or more poloxamer to CSA is between about 30 to 1 to about 3 to 1.In some embodiments, the poloxamer is Pluronic F127.

The amount of poloxamer may be based upon a weight percentage of thecomposition. In some embodiments, the amount of poloxamer is about 10%,15%, 20%, 25%, 30%, 35%, 40%, about any of the aforementioned numbers,or a range bounded by any two of the aforementioned numbers or theformulation. In some embodiments, the one or more poloxamer is betweenabout 10% to about 40% by weight of a formulation administered to thepatient. In some embodiments, the one or more poloxamer is between about20% to about 30% by weight of the formulation. In some embodiments, theformulation contains less than about 50%, 40%, 30%, 20%, 10%, 5%, or 1%of CSA, or about any of the aforementioned numbers. In some embodiments,the formulation contains less than about 20% by weight of CSA.

The above described poloxamer formulations are particularly suited forthe applications described herein, including the described methods oftreatment, device coatings, preparation of unit dosage forms (i.e.,solutions, mouthwashes, injectables), etc.

In one embodiment, the compounds described herein may be formulated fororal administration in a lipid-based formulation suitable for lowsolubility compounds. Lipid-based formulations can generally enhance theoral bioavailability of such compounds.

As such, a pharmaceutical composition comprises a therapeutically orprophylactically effective amount of a compound described herein,together with at least one pharmaceutically acceptable excipientselected from the group consisting of medium chain fatty acids orpropylene glycol esters thereof (e.g., propylene glycol esters of ediblefatty acids such as caprylic and capric fatty acids) andpharmaceutically acceptable surfactants such as polyoxyl 40 hydrogenatedcastor oil.

In an alternative preferred embodiment, cyclodextrins may be added asaqueous solubility enhancers. Preferred cyclodextrins includehydroxypropyl, hydroxyethyl, glucosyl, maltosyl and maltotriosylderivatives of α-, β-, and γ-cyclodextrin. A particularly preferredcyclodextrin solubility enhancer is hydroxypropyl-o-cyclodextrin (BPBC),which may be added to any of the above-described compositions to furtherimprove the aqueous solubility characteristics of the compounds of theembodiments. In one embodiment, the composition comprises about 0.1% toabout 20% hydroxypropyl-o-cyclodextrin, more preferably about 1% toabout 15% hydroxypropyl-o-cyclodextrin, and even more preferably fromabout 2.5% to about 10% hydroxypropyl-o-cyclodextrin. The amount ofsolubility enhancer employed will depend on the amount of the compoundof the embodiments in the composition.

In some exemplary embodiments, a CSA comprises a multimer (e.g., adimer, trimer, tetramer, or higher order polymer). In some exemplaryembodiments, the CSAs can be incorporated into pharmaceuticalcompositions or formulations. Such pharmaceuticalcompositions/formulations are useful for administration to a subject, invivo or ex vivo. Pharmaceutical compositions and formulations includecarriers or excipients for administration to a subject.

Such formulations include solvents (aqueous or non-aqueous), solutions(aqueous or non-aqueous), emulsions (e.g., oil-in-water orwater-in-oil), suspensions, syrups, elixirs, dispersion and suspensionmedia, coatings, isotonic and absorption promoting or delaying agents,compatible with pharmaceutical administration or in vivo contact ordelivery. Aqueous and non-aqueous solvents, solutions and suspensionsmay include suspending agents and thickening agents. Suchpharmaceutically acceptable carriers include tablets (coated oruncoated), capsules (hard or soft), microbeads, powder, granules andcrystals. Supplementary active compounds (e.g., preservatives,antibacterial, antiviral and antifungal agents) can also be incorporatedinto the compositions.

Cosolvents and adjuvants may be added to the formulation. Non-limitingexamples of cosolvents contain hydroxyl groups or other polar groups,for example, alcohols, such as isopropyl alcohol; glycols, such aspropylene glycol, polyethyleneglycol, polypropylene glycol, glycolether; glycerol; polyoxyethylene alcohols and polyoxyethylene fatty acidesters. Adjuvants include, for example, surfactants such as, soyalecithin and oleic acid; sorbitan esters such as sorbitan trioleate; andpolyvinylpyrrolidone.

A pharmaceutical composition and/or formulation contains a total amountof the active ingredient(s) sufficient to achieve an intendedtherapeutic effect.

The term “packaging material” refers to a physical structure housing oneor more components of the kit. The packaging material can maintain thecomponents sterilely, and can be made of material commonly used for suchpurposes (e.g., paper, corrugated fiber, glass, plastic, foil, ampules,vials, tubes, etc.). A kit can contain a plurality of components, e.g.,two or more compounds alone or in combination with an osteogenesis agentor treatment or drug, optionally sterile.

A kit optionally includes a label or insert including a description ofthe components (type, amounts, doses, etc.), instructions for use invitro, in vivo, or ex vivo, and any other components therein. Labels orinserts include “printed matter,” e.g., paper or cardboard, or separateor affixed to a component, a kit or packing material (e.g., a box), orattached to an ampule, tube or vial containing a kit component. Labelsor inserts can additionally include a computer readable medium, such asa disk (e.g., floppy diskette, hard disk, ZIP disk), optical disk suchas CD- or DVD-ROM/RAM, DVD, MP3, magnetic tape, or an electrical storagemedia such as RAM and ROM or hybrids of these such as magnetic/opticalstorage media, FLASH media or memory type cards.

One of ordinary skill in the art to which these exemplary embodimentsbelong will understand that the compositions may be administered innumerous ways. In some exemplary embodiments, administration may beenteral, parenteral, or topical. Other exemplary routes ofadministration for contact or in vivo delivery which a compound canoptionally be formulated include inhalation, respiration, intubation,intrapulmonary instillation, oral (buccal, sublingual, mucosal),intrapulmonary, rectal, vaginal, intrauterine, intradermal, topical,dermal, parenteral (e.g., subcutaneous, intramuscular, intravenous,intradermal, intraocular, intratracheal and epidural), intranasal,intrathecal, intraarticular, intracavity, transdermal, iontophoretic,ophthalmic, optical (e.g., corneal), intraglandular, intraorgan, and/orintralymphatic.

The delivery forms can be homogeneous, e.g., forms in which thecomposition is in solution, or heterogeneous, e.g., forms in which thecomposition is contained within liposomes or microspheres. The forms canproduce an immediate effect, and can alternatively, or additionally,produce an extended effect. For example, liposomes, or microspheres, orother similar means of providing an extended release of the composition,can be used to extend the period during which the composition is exposedto the targeted area; non-encapsulated compositions can also be providedfor an immediate effect.

In some embodiments, the composition or method includes administering aCSA from a pharmaceutically acceptable device(s) such as bandages,surgical dressings, gauzes, adhesive strips, surgical staples, clips,hemostats, intrauterine devices, sutures, trocars, catheters, tubes, andimplants. In some embodiments, the implant is a pill, pellet, rod,screw, wafer, disc, and/or tablet. The devices can deliver thecomposition to a targeted area for a desired period of time. In someexemplary embodiments, the composition may be incorporated into amedical device coating. In some embodiments, the coating contains CSA as0.1% by weight, 1% by weight, 5% by weight, 10% by weight, 15% byweight, 20% by weight, 25% by weight, 50% by weight, about any of theaforementioned numbers, and/or a range bounded by any two of theaforementioned numbers. In some embodiments, the thickness of thecoating on the device depends on the desired elution profile andlongevity of the device. Thicknesses may be about 1 nm, 50 nm, 100 nm,500 nm, 1 μm, 10 μm, 50 μm, 100 μm, 250 μm, 500 μm, 750 μm, or 1000 μm,a range bounded by any two of the aforementioned numbers, or at leastabout any of the aforementioned numbers, or less than about any of theaforementioned numbers.

Devices according to the disclosure can be prepared according to knownmethods, and can include, or be made from, polymeric material. In someinstances, the polymeric material will be an absorbable material and inother instances, a non-absorbable material, or in other instances aresorbable material. Devices can, of course, include absorbable,non-absorbable, resorbable materials, and combinations thereof.

Absorbable materials can be synthetic materials and non-syntheticmaterials. Absorbable synthetic materials include, but are not limitedto, cellulosic polymers, glycolic acid polymers, methacrylate polymers,ethylene vinyl acetate polymers, ethylene vinyl alcohol copolymers,polycaptrolactam, polyacetate, copolymers of lactide and glycolide,polydioxanone, polyglactin, poliglecaprone, polyglyconate,polygluconate, and combinations thereof. Absorbable non-syntheticmaterials include, but are not limited to, catgut, cargile membrane,fascia lata, gelatin, collagen, and combinations thereof.

Nonabsorbable synthetic materials include, but are not limited tonylons, rayons, polyesters, polyolefins, and combinations thereof.Non-absorbable non-synthetic materials include, but are not limited to,silk, dermal silk, cotton, linen, and combinations thereof.

Combinations of the foregoing devices and carriers/vehicles are alsoenvisioned. For example, a CSA composition, gel, or ointment can beimpregnated into a bandage or wound dressing for delivery of the CSA toa targeted location. As another example, an implantable absorbabledevice can be loaded with a CSA material and release the CSA from thedevice over a desired period. Sustained or controlled releaseformulations, compositions, or devices can be used. A desired period ofdelivery can be, for example, at least about 2, 3, 6, 10, 12, 18, or 24hours, or 1, 2, 4, 8, 12, 20, or 30 days, or 1, 2, 3, 4, 5, 6, or moremonths, and any value in between. The physical form used to deliver theCSA is not critical and the choice or design of such devices is wellwithin the level of skill of one in the art.

It may be desirable to provide for other conditions in the practice ofthe present methods. For example, it may be desirable to ensure that thetarget region is sufficiently oxygenated; generally, it is sufficientthat atmospheric oxygen be present. It also may be desirable to maintaina desired level of moisture and a particular temperature; in someembodiments, a warm, moist environment is desirable. While not required,it may also be desirable to establish or maintain a sterile environment.

Additionally, it may be desirable to include other therapeuticallybeneficial agents in the formulation. For example, the vehicles orcarriers may also include humectants or moisturizers to maintain adesired moisture level in the treated area. Other possibilities includedrugs such as anesthetics or antibiotics, which provide other desiredeffects. Again, the possibilities are unlimited and are left to thepractitioner. In some exemplary embodiments the composition may comprisea second CSA for purposes for which CSAs are known to serve.

In some embodiments, the CSAs are adsorbed on and/or dispersed within apolymer matrix. In some embodiments, the polymer matrix is bioerodable.In some embodiments, the polymer matrix is mucoadhesive. In someembodiments, the polymer matrix is configured to fit in the mouth of asubject. In some embodiments, the polymer matrix may have an adhesive onone or more surfaces.

Dosages

The formulations may, for convenience, be prepared or provided as a unitdosage form. Preparation techniques include bringing into associationthe active ingredient (e.g., CSA) and a pharmaceutical carrier(s) orexcipient(s). In general, formulations are prepared by uniformly andintimately associating the active ingredient with liquid carriers orfinely divided solid carriers or both, and then, if necessary, shapingthe product. For example, a tablet may be made by compression ormolding. Compressed tablets may be prepared by compressing, in asuitable machine, an active ingredient (e.g., a CSA) in a free-flowingform such as a powder or granules, optionally mixed with a binder,lubricant, inert diluent, preservative, surface-active or dispersingagent. Molded tablets may be produced by molding, in a suitableapparatus, a mixture of powdered compound (e.g., CSA) moistened with aninert liquid diluent. The tablets may optionally be coated or scored andmay be formulated so as to provide a slow or controlled release of theactive ingredient therein.

Compounds (e.g., CSAs), including pharmaceutical formulations can bepackaged in unit dosage forms for ease of administration and uniformityof dosage. A “unit dosage form” as used herein refers to a physicallydiscrete unit suited as unitary dosages for the subject to be treated;each unit containing a predetermined quantity of compound optionally inassociation with a pharmaceutical carrier (excipient, diluent, vehicleor filling agent) which, when administered in one or more doses, iscalculated to produce a desired effect (e.g., prophylactic ortherapeutic effect or benefit). Unit dosage forms can contain a dailydose or unit, daily sub-dose, or an appropriate fraction thereof, of anadministered compound (e.g., CSA). Unit dosage forms also include, forexample, capsules, troches, cachets, lozenges, tablets, ampules andvials, mouthwash, etc. which may include a composition in a freeze-driedor lyophilized state; a sterile liquid carrier, for example, can beadded prior to administration or delivery in vivo. Unit dosage formsadditionally include, for example, bottles, ampules, and vials withliquid compositions disposed therein. Unit dosage forms further includecompounds for transdermal administration, such as “patches” that contactwith the epidermis of the subject for an extended or brief period oftime. The individual unit dosage forms can be included in multi-dosekits or containers. Pharmaceutical formulations can be packaged insingle or multiple unit dosage forms for ease of administration anduniformity of dosage.

Compounds (e.g., CSAs) can be administered in accordance with themethods at any frequency as a single bolus or multiple dose e.g., one,two, three, four, five, or more times hourly, daily, weekly, monthly, orannually or between about 1 to 10 days, weeks, months, or for as long asappropriate. Exemplary frequencies are typically from 1-7 times, 1-5times, 1-3 times, 2-times or once, daily, weekly or monthly. Timing ofcontact, administration ex vivo or in vivo delivery can be dictated bythe infection, pathogenesis, symptom, pathology or adverse side effectto be treated. For example, an amount can be administered to the subjectsubstantially contemporaneously with, or within about 1-60 minutes orhours of the onset of a symptom or adverse side effect, pathogenesis, orvaccination. Long-acting pharmaceutical compositions may be administeredtwice a day, once a day, once every two days, three times a week, twicea week, every 3 to 4 days, or every week depending on half-life andclearance rate of the particular formulation. For example, in anembodiment, a pharmaceutical composition contains an amount of acompound as described herein that is selected for administration to apatient on a schedule selected from: twice a day, once a day, once everytwo days, three times a week, twice a week, and once a week.

Localized delivery is also contemplated, including but not limited todelivery techniques in which the compound is implanted, injected,infused, or otherwise locally delivered. Localized delivery ischaracterized by higher concentrations of drug at the site of desiredaction versus systemic concentrations of the drug. Well-known localizeddelivery forms can be used, including long-acting injections; infusiondirectly into the site of action; depot delivery forms; controlled orsustained delivery compositions; transdermal patches; infusion pumps;and the like. In some instances, the intended treatment area can bewashed, rinsed, sprayed, or inundated with a CSA composition. As anon-limiting example, the CSA composition is formulated as a mouthwashand the desired treatment area is an oral cavity, such as the mouth. Insome embodiments, the CSA can further be incorporated into abiodegradable or bioerodible material or be put into or on a medicaldevice.

Doses may vary depending upon whether the treatment is therapeutic orprophylactic, the onset, progression, severity, frequency, duration,probability of or susceptibility of the symptom, the type pathogenesisto which treatment is directed, clinical endpoint desired, previous,simultaneous or subsequent treatments, general health, age, gender orrace of the subject, bioavailability, potential adverse systemic,regional or local side effects, the presence of other disorders ordiseases in the subject, and other factors that will be appreciated bythe skilled artisan (e.g., medical or familial history). Dose amount,frequency or duration may be increased or reduced, as indicated by theclinical outcome desired, status of the infection, symptom or pathology,any adverse side effects of the treatment or therapy. The skilledartisan will appreciate the factors that may influence the dosage,frequency and timing required to provide an amount sufficient oreffective for providing a prophylactic or therapeutic effect or benefit.The exact dosage will be determined by the practitioner, in light offactors related to the subject that requires treatment. Dosage andadministration are adjusted to provide sufficient levels of the activeagent(s) or to maintain the desired effect. It will be appreciated thattreatment as described herein includes preventing a disease,ameliorating symptoms, slowing disease progression, reversing damage, orcuring a disease.

The dosage may range broadly, depending upon the desired effects and thetherapeutic indication. Alternatively dosages may be based andcalculated upon the surface area of the patient, as understood by thoseof skill in the art. Although the exact dosage will be determined on adrug-by-drug basis, in most cases, some generalizations regarding thedosage can be made. The systemic daily dosage regimen for an adult humanpatient may be, for example, an oral dose of between 0.01 mg and 3000 mgof the active ingredient, preferably between 1 mg and 700 mg, e.g. 5 to200 mg. The dosage may be a single one or a series of two or more givenin the course of one or more days, as is needed by the subject. In someembodiments, the compounds will be administered for a period ofcontinuous therapy, for example for a week or more, or for months oryears. Doses tailored for particular types of the diseases describedherein, or for particular patients, can be selected based, in part, onthe GI₅₀, TGI, and LC₅₀ values set forth in the Examples that follow.

In instances where human dosages for compounds have been established forat least some condition, those same dosages may be used, or dosages thatare between about 0.1% and about 500%, more preferably between about 25%and about 250% of the established human dosage. Where no human dosage isestablished, as will be the case for newly-discovered pharmaceuticalcompositions, a suitable human dosage can be inferred from ED₅₀ or ID₅₀values, or other appropriate values derived from in vitro or in vivostudies, as qualified by toxicity studies and efficacy studies inanimals.

In cases of administration of a pharmaceutically acceptable salt,dosages may be calculated as the free base. As will be understood bythose of skill in the art, in certain situations it may be necessary toadminister the compounds disclosed herein in amounts that exceed, oreven far exceed, the above-stated, preferred dosage range in order toeffectively and aggressively treat particularly aggressive diseases orconditions.

Dosage amount and interval may be adjusted individually to provideplasma levels of the active moiety which are sufficient to maintain themodulating effects, or minimal effective concentration (MEC). Forexample, therapeutic dosages may result in plasma levels of 0.05 μg/mL,0.1 μg/mL, 0.5 μg/mL, 1 μg/mL, 5 μg/mL, 10 μg/mL, 15 μg/mL, 20 μg/mL, 25μg/mL, 30 μg/mL, 35 μg/mL, 40 μg/mL, 45 μg/mL, 50 μg/mL, 55 μg/mL, 60μg/mL, 65 μg/mL, 70 μg/mL, 75 μg/mL, 80 μg/mL, 85 μg/mL, 90 μg/mL, 95μg/mL, 100 μg/mL, a range bounded by any two of the aforementionednumbers, or about any of the aforementioned numbers and ranges. In someembodiments, the therapeutic dose is sufficient to establish plasmalevels in the range of about 0.1 μg/mL to about 10 μg/mL. In otherembodiments, the therapeutic dose is sufficient to establish plasmalevels in the range of 1 μg/mL to about 20 μg/mL. The MEC will vary foreach compound but can be estimated from in vitro data. Dosages necessaryto achieve the MEC will depend on individual characteristics and routeof administration. However, HPLC assays or bioassays can be used todetermine plasma concentrations. Dosage intervals can also be determinedusing MEC value. Compositions should be administered using a regimenwhich maintains plasma levels above the MEC for 10-90% of the time,preferably between 30-90% and most preferably between 50-90%. In casesof local administration or selective uptake, the effective localconcentration of the drug may not be related to plasma concentration.

Compounds disclosed herein can be evaluated for efficacy and toxicityusing known methods. For example, the toxicology of a particularcompound, or of a subset of the compounds, sharing certain chemicalmoieties, may be established by determining in vitro toxicity towards acell line, such as a mammalian, and preferably human, cell line. Theresults of such studies are often predictive of toxicity in animals,such as mammals, or more specifically, humans. Alternatively, thetoxicity of particular compounds in an animal model, such as mice, rats,rabbits, or monkeys, may be determined using known methods. The efficacyof a particular compound may be established using several recognizedmethods, such as in vitro methods, animal models, or human clinicaltrials. When selecting a model to determine efficacy, the skilledartisan can be guided by the state of the art to choose an appropriatemodel, dose, route of administration and/or regime.

As described herein, the methods of the embodiments also include the useof a compound or compounds as described herein together with one or moreadditional therapeutic agents for the treatment of disease conditions.Thus, for example, the combination of active ingredients may be: (1)co-formulated and administered or delivered simultaneously in a combinedformulation; (2) delivered by alternation or in parallel as separateformulations; or (3) by any other combination therapy regimen known inthe art. When delivered in alternation therapy, the methods describedherein may comprise administering or delivering the active ingredientssequentially, e.g., in separate solution, emulsion, suspension, tablets,pills or capsules, or by different injections in separate syringes. Ingeneral, during alternation therapy, an effective dosage of each activeingredient is administered sequentially, i.e., serially, whereas insimultaneous therapy, effective dosages of two or more activeingredients are administered together. Various sequences of intermittentcombination therapy may also be used.

Some embodiments are directed to the use of companion diagnostics toidentify an appropriate treatment for the patient. A companiondiagnostic is an in vitro diagnostic test or device that providesinformation that is essential for the safe and effective use of acorresponding therapeutic product. Such tests or devices can identifypatients likely to be at risk for adverse reactions as a result oftreatment with a particular therapeutic product. Such tests or devicescan also monitor responsiveness to treatment (or estimate responsivenessto possible treatments). Such monitoring may include schedule, dose,discontinuation, or combinations of therapeutic agents. In someembodiments, the CSA is selected by measuring a biomarker in thepatient. The term biomarker includes, but is not limited to, geneticregulation, protein levels, RNA levels, and cellular responses such ascytotoxicity. In some embodiments, one or more CSAs are selected bysubjecting a sample from the patient to a companion diagnostic device.In some embodiments, the sample is a tissue sample. In otherembodiments, the tissue sample is representative of the area to betreated. In some embodiments, the tissue sample contains a portion ofthe area to be treated. In some embodiments, the studied biomarker is acellular response to the CSA or the companion diagnostic device measuresa cellular response to the CSA. In some embodiments, the cellularresponse is a change in mRNA levels associated with inflammation.

Examples Synthesis of CSAs

Compounds described herein can be prepared by known methods, such asthose disclosed in U.S. Pat. No. 6,350,738, which are incorporatedherein by reference. A skilled artisan will readily understand thatminor variations of starting materials and reagents may be utilized toprepare known and novel cationic steroidal antimicrobials. For example,the preparation of CSA-13 disclosed in U.S. Pat. No. 6,350,738 (compound133) can be used to prepare CSA-92 by using hexadecylamine rather thanoctyl amine as disclosed. Schematically, for example, the preparation ofcertain compounds can be accomplished as follows:

As shown above, compound 1-A is converted to the mesylate, compound 1-Busing known conditions. Treatment of compound 1-B with a secondaryamine, such as HNR₁R₂, results in the formation of compound 1-C, whoseazido functional groups are reduced with hydrogen gas in the presence ofa suitable catalyst to afford compound 1-D. Suitable catalysts includePalladium on Carbon and Lindlar catalyst. The reagent HNR₁R₂ is notparticularly limited under this reaction scheme. For example, when R₁ ishydrogen and R₂ is a C₈-alkyl, CSA-13 is obtained from the synthesis.When R₁ is hydrogen and R₂ is a Cm-alkyl, CSA-92 is obtained from thesynthesis. When R₁ and R₂ are both C₅-alkyl, CSA-90 is obtained from thesynthesis.

Inflammation Gene Regulation

To determine the role of synthetic Ceragenins CSA-13, 44 and 90 ininflammation using mesenchymal stem cells (MSC), targeted mRNA panelsfrom SABiosciences, and primary cells from Lonza were selected. Cellswere purchased from Lonza.com and used fresh for each test usingrecommended media and culture conditions. After treatment, mRNA wasisolated using Qiagen RNeasy Mini Kit®, and quantified using a NanoDrop2000® by UV at 260 nm and 260/280 ratio for purity. cDNA was made usinga First Strand Kit® from SABiosciences and processed for real time PCRusing a kit from the same company for selected analysis of wound healingpathways. Results from q-PCR were uploaded to the SABiosciences site andto Ingenuity.com web site for analysis and pathway mapping. On day 1,primary human MSC cells were plated at 200,000 cells/well using 6-wellplates with 3 ml of recommended media—hMSC Basal Medium+BulletKit (50 mlGrowth Supplement, 10 ml L-Glutamine and 0.5 ml Gentamicin SulfateAmphotercin-B) for 24 hours. Only early passages of cells were used, andnever from frozen stock. On day 2, cells were treated with compoundsdissolved in DMSO diluted 1:1000 or more to avoid effects of thesolvent. Final testing concentration for CSA-13 was 5.0 μM. Treatmentlasted 8 hours, and was followed by RNA isolation using QIAGEN RNeasyMini Kit® (74104). RNA was measured at 260/280 nm using a NanoDrop 2000®and normalized to 2.4 ng per well, cDNA preparation was done usingQIAGEN First Strand kit 330401. q-PCR was run as absolute quantificationand threshold set at 0.1 units. Dendritic cells were plated at 500,000cells/well using 24-well plate with 500 μl of Lonza LGM-3 CompleteGrowth Medium with and without compound. Treatment lasted 8 hours, andwas followed by RNA isolation using QIAGEN RNeasy Mini Kit® (74104). RNAwas measured at 260/280 nm using NanoDrop2000® and normalized to 2.4 ngper well, cDNA preparation was done using QIAGEN First Strand kit330401. PCR was run as absolute quantification and threshold set at 0.1units. The results of these experiments are summarized in Tables 1-3 forCSA-13, 44, and 90, respectively. The results highly the significantmodulation of genes related to inflammation, such as IL1A (Interleukin-1alpha), IL1B (Interleukin-1 beta), TLR2 (Toll-like receptor 2), TLR4(Toll-like receptor 4), TLR6 (Toll-like receptor 6), TLR8 (Toll-likereceptor 8), TLR9 (Toll-like receptor 9), TNF (Tumor necrosis factor),TNFRSF1A (Tmor necrosis factor receptor superfamily member 1A), IRAK2(Interleukin-1 receptor-associated kinase 2), NFKB1 (Nuclear factor ofkappa light polypeptide gene enhancer in B-cells 1), NFKB2 (Nuclearfactor of kappa light polypeptide gene enhancer in B-cells 2), andNFKBIA (Nuclear factor of kappa light polypeptide gene enhancer inB-cells inhibitor, alpha). Such results clearly illustrate the potentialof CSAs for modulating inflammation.

TABLE 1 Gene Expression Results for CSA-13 Gene Symbol Fold RegulationIL1A −5.5237 IL1B −16.3901 TLR2 −7.6418 TLR4 −2.6139 TLR6 −4.8417 TLR8−2.107 TLR9 −2.1421 TNF −8.1805 TNFRSF1A −5.1031 IRAK2 −43.5175 NFKB1−3.4437 NFKB2 −4.2155 NFKBIA −22.966

TABLE 2 Gene Expression Results for CSA-44 Gene Symbol Fold RegulationIL1A −6.0325 IL1B −28.5329 IRAK2 −31.8021 NFKB1 −3.2891 NFKB2 −2.2766NFKBIA −52.206 TLR2 −15.7179 TLR4 −2.977 TLR6 −2.392 TLR8 −8.2256 TLR9−1.8905 TNF −25.9588 TNFRSF1A −2.2461

TABLE 3 Gene Expression Results for CSA-90 Gene Symbol Fold RegulationIL1A −6.96 1L1B −3.6734 IRAK2 −52.0069 NFKB1 −4.718 NFKB2 −2.5474 NFKBIA−26.0352 TLR2 −13.6933 TLR4 −3.4278 TLR6 −2.0885 TLR8 −4.1972 TLR9−1.8613 TNF −4.8514 TNFRSF1A −7.3196

Animal Model of Periodontitis:

CSA compounds and formulations are tested for the ability to eradicateinfection by P. gingivalis and prevent alveolar bone loss in ratligature model of periodontal disease. The rat ligature model isrecognized as one of several models for evaluating the efficacy oftopical formulations for treatment and/or prevention of periodontitis.Briefly, experimental periodontitis will be induced in 4 groups of 8rats (sham treatment control, two treatment groups to evaluate twodifferent CSA compounds and formulations, and one group of low dose ofCSA compounds and formulation with the anti-inflammatory agentcimetidine) by placing silk sutures tied around the mandibular secondpremolars bilaterally, followed by the topical application of 10⁹ CFU ofP. gingivalis. After 14 days treatment, the compounds and formulationsare administered every other day continuing through day 42. Thecompounds and formulations are swabbed around the rat mouth and on theteeth. Volumes of 500 μL are used to ensure that sufficient material ispresent to coat the mouth and teeth. At the highest dose, this would beaddition of 50 μg of CSA. In preliminary oral toxicity testing withrats, doses 1,000 times higher are well tolerated. Consequently, it isanticipated that toxicity will not be an issue.

At day 42 the study animals are euthanized. Mandibular block sectionsare obtained and tissues decalcified and embedded in paraffin. Thinsections (5 microns) are stained with hematoxylin and eosin. Macroscopicand histologic evaluation of the samples are conducted followed bycharacterization of cellular inflammatory infiltrate and quantitativehistomorphometric measurements. Representative photographic images arealso obtained. Alveolar bone loss is evaluated with the use of MicroCTscanning. Statistical analysis is also performed.

Alveolar bone loss associated with periodontitis is caused byinflammatory responses to bacterial infection and biofilm formation. Asdescribed above, deficiencies in antimicrobial peptides result in severeperiodontitis. The endogenous antimicrobial peptide LL-37 displaysantibacterial activity and anti-inflammatory activity. LL-37 sequestersbacterial membrane components, such as lipopolysaccharide andlipoteichoic acid that lead to inflammatory responses. Similarly, CSAsare expected to bind these bacterial lipids and thereby preventinflammatory responses. This dual mode of action is expected to be veryeffective in limiting bacterial burden and in inhibiting inflammatoryresponses leading to alveolar bone loss. To separate these two effects,one series of experiments is performed with the anti-inflammatorycimetidine. Topical application of this compound was recently shown toreduce alveolar bone loss in a model of periodontal disease. Comparisonof CSAs and CSA formulation (i.e., prepared with a surfactant such aspluronic), with and without cimetidine affords a method to evaluate theinflammatory properties of the test compounds and formulations in thismodel.

Animal Model of Pain/Inflammation:

Adult Male Sprague Dawley rats (200-250 g) are maintained on a 12/12hour light/dark cycle with food and water ad libitum. Rats areacclimated for a week before use in experiments. Rats are anesthetizedbriefly with isoflurane (5% induction, then 2% maintenance) and theirleft foot is swabbed with ethanol. Complete Freund's adjuvant (“CFA”)0.15 mL is injected subcutaneously into the plantar surface of the lefthind paw of the rat. The CFA injection immediately induces localinflammation, paw swelling, and pain. For behavior studies, rats areplaced on the equipment and left to acclimate for 30 minutes. On day 0,baseline measurements are read and rats are injected with CFAthereafter. On day 3, post-CFA reads are taken and only rats that metcriteria of hyperalgesia are placed on the study on day 4.

To assess mechanical allodynia, rats are placed on an elevated wire meshplatform, and to confine their movement, a 15×22×25 cm plexiglasschamber is placed over each animal. Mechanical paw withdrawal thresholds(“PWT”) are measured by using a set of Semmes Weinstein monofilamentsusing the Dixon up and down method. Only rats that displayed a PWT of 8g or less on day 3 (post-CFA) are placed on study. To assess thermalhyperalgesia rats are placed on glass plates with the source of heatapplied from the bottom. On day 3 (post-CFA) rats that gave withdrawallatencies of 6 s or less are included in the experiments. Rats are thenrandomly assigned to either a vehicle group or drug group. On day 4,rats are treated with either the vehicle (saline), or drug (CSA,formulated CSA, or co-administration of CSA with anti-inflammatoryand/or pain reliever) and reads are taken 2 hrs after the treatment. Alldrugs/vehicle are administered by oral gavage at 5 mg/kg/ml. Statisticalanalysis of behavioral data is performed using a one way ANOVA followedby the Student-Newman-Keul's Post-Hoc test.

Inflammatory Markers Secondary to Pneumonia

IL-6 is a marker of systemic inflammation. Female C57/BL6 mice wereinfected in the respiratory tract with a non-lethal dose of P.aeruginosa as a model of pneumonia. One cohort (n=6) also received 80mg/kg CSA-13; a second cohort (n=6) also received 40 mg/kg CSA-13; athird (n=6) received no CSA treatment; and a fourth (n=6) was notinfected. Examination of IL-6 levels in the kidneys 24 hourspost-infection demonstrated that those infected animals not treated withCSA had IL-6 levels >15 times those of control and 5-10 times higherthan those of the CSA-treated animals. Thus, treatment with CSAsignificantly reduced kidney IL-6 levels in a pneumonia model.

Additional Animal Model of Pain

Application of a heat lamp to the hind paws of mice is used to determinesensitivity to painful thermal stimuli. During these tests the animalsare awake and can behave freely within the confines of the cage. In thethermal sensitivity assay, the time it takes before the animal withdrawsits paw from the heat source (hind paw withdrawal latency, HPWL) istaken as the measure of thermal sensitivity. To examine the influence ofagents on nocifensive behavior, cumulative dose response relationshipsare tested, wherein an aliquot of CSA is administered every 60 minutesby i.p injection.

CONCLUSION

Furthermore, although the foregoing has been described in some detail byway of illustrations and examples for purposes of clarity andunderstanding, it will be understood by those of skill in the art thatnumerous and various modifications can be made without departing fromthe spirit of the present disclosure. Therefore, it should be clearlyunderstood that the forms disclosed herein are illustrative only and arenot intended to limit the scope of the present disclosure, but rather toalso cover all modification and alternatives coming with the true scopeand spirit of the invention.

What is claimed is:
 1. A method of treating, reducing, or preventing adisease selected from oral mucositis, gastric mucositis, or inflammatoryfibrosis, the method comprising: identifying a patient in need oftreating, reducing, or preventing a disease selected from oralmucositis, gastric mucositis, or inflammatory fibrosis; andadministering a therapeutically or prophylactically effective amount ofat least one cationic steroidal antimicrobial (CSA), or apharmaceutically acceptable salt thereof to treat, reduce, or preventsaid disease.
 2. The method of claim 1, wherein the pharmaceuticallyacceptable salt is a mono-hydrochloride salt, a di-hydrochloride salt, atri-hydrochloride salt, or a tetra-hydrochloride salt.
 3. The method ofclaim 1, further comprising administering an antibiotic to the patient,wherein the antibiotic is selected from the group consisting of anaminoglycoside, an ansamycin, a carbacephem, a carbapenem, acephalosporin, a glycopeptide, a lincosamide, a lipopeptide, amacrolide, a monbactam, a nitrofuran, an oxazolidonone, a penicillin, apolypeptide, a quinolone, a sulfonamide, and a tetracycline.
 4. Themethod of claim 1, further comprising administering a non-CSAanti-inflammatory agent.
 5. The method of claim 1, wherein the CSA iscomplexed with albumin or a surfactant.
 6. The method of claim 1,wherein the CSA is complexed with one or more poloxamer surfactant. 7.The method of claim 6, wherein the one or more poloxamer surfactant hasa molecular weight of about 3600 g/mol for the central hydrophobic chainof polyoxypropylene and has about 70% polyoxyethylene content.
 8. Themethod of claim 6, wherein the ratio of the one or more poloxamer to CSAis between about 50 to 1 to about 1 to 50 or between about 30 to 1 toabout 3 to
 1. 9. The method of claim 6, wherein the one or morepoloxamer is between about 10% to about 40% by weight or between about20% to about 30% by weight of a formulation administered to the patient.10. The method of claim 6, wherein the CSA is administered in aformulation containing less than about 20% by weight of CSA.
 11. Themethod of claim 1, wherein the CSA is selected by measuring a biomarkeror subjecting a sample from the patient to a companion diagnostic test.12. The method of claim 11, wherein the biomarker is a cellular responseto the CSA or the companion diagnostic test measures a cellular responseto the CSA.
 13. The method of claim 12, wherein the biomarker isselected from the group consisting of IL-1A, IL-1B, IL-6, TLR2, TLR4,TLR6, TLR8, TLR9, TNFRSF1A, TNF, TNF-beta 1, CCL2, CXCR4, IRAK2, NFKB1,NFKB2, NFKB1A, and miR-29d.
 14. The method of claim 1, wherein thedisease is oral mucositis.
 15. The method of claim 1, wherein thedisease is gastric mucositis.
 16. The method of claim 1, wherein thedisease is inflammatory fibrosis.
 17. The method of claim 1, wherein thetreating, reducing, or preventing a disease is independent of CSAantibiotic activity.
 18. The method of claim 1, wherein the patient is amammal.
 19. The method of claim 18, wherein the mammal is a human. 20.The method of claim 1, wherein the CSA is a compound of Formula (I) or apharmaceutically acceptable salt thereof:

wherein rings A, B, C, and D are independently saturated, or are fullyor partially unsaturated, provided that at least two of rings A, B, C,and D are saturated; m, n, p, and q are independently 0 or 1; R₁ throughR₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, and R₁₈ are independently selected fromthe group consisting of hydrogen, hydroxyl, a substituted orunsubstituted alkyl, a substituted or unsubstituted hydroxyalkyl, asubstituted or unsubstituted alkyloxyalkyl, a substituted orunsubstituted alkylcarboxyalkyl, a substituted or unsubstitutedalkylaminoalkyl, a substituted or unsubstituted alkylaminoalkylamino, asubstituted or unsubstituted alkylaminoalkylaminoalkylamino, asubstituted or unsubstituted aminoalkyl, a substituted or unsubstitutedaryl, a substituted or unsubstituted arylaminoalkyl, a substituted orunsubstituted haloalkyl, a substituted or unsubstituted alkenyl, asubstituted or unsubstituted alkynyl, oxo, a linking group attached to asecond steroid, a substituted or unsubstituted aminoalkyloxy, asubstituted or unsubstituted aminoalkyloxyalkyl, a substituted orunsubstituted aminoalkylcarboxy, a substituted or unsubstitutedaminoalkylaminocarbonyl, a substituted or unsubstitutedaminoalkylcarboxamido, a substituted or unsubstituteddi(alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—, H₂N—HC(Q₅)-C(O)—N(H)—, asubstituted or unsubstituted azidoalkyloxy, a substituted orunsubstituted cyanoalkyloxy, P.G.-HN—HC(Q₅)-C(O)—O—, a substituted orunsubstituted guanidinoalkyloxy, a substituted or unsubstitutedquaternaryammoniumalkylcarboxy, and a substituted or unsubstitutedguanidinoalkyl carboxy, where Q₅ is a side chain of any amino acid(including a side chain of glycine, i.e., H), and P.G. is an aminoprotecting group; and R₅, R₈, R₉, R₁₀, R₁₃, R₁₄ and R₁₇ areindependently deleted when one of rings A, B, C, or D is unsaturated soas to complete the valency of the carbon atom at that site, or R₅, R₈,R₉, R₁₀, R₁₃, and R₁₄ are independently selected from the groupconsisting of hydrogen, hydroxyl, a substituted or unsubstituted alkyl,a substituted or unsubstituted hydroxyalkyl, a substituted orunsubstituted alkyloxyalkyl, a substituted or unsubstituted aminoalkyl,a substituted or unsubstituted aryl, a substituted or unsubstitutedhaloalkyl, a substituted or unsubstituted alkenyl, a substituted orunsubstituted alkynyl, oxo, a linking group attached to a secondsteroid, a substituted or unsubstituted aminoalkyloxy, a substituted orunsubstituted aminoalkylcarboxy, a substituted or unsubstitutedaminoalkylaminocarbonyl, a substituted or unsubstituteddi(alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—, H₂N—HC(Q₅)-C(O)—N(H)—,azidoalkyloxy, cyanoalkyloxy, P.G.-HN—HC(Q₅)-C(O)—O—, guanidinoalkyloxy,and guanidinoalkylcarboxy, where Q₅ is a side chain of any amino acid,P.G. is an amino protecting group, provided that at least two or threeof R₁₋₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, R₁₇, and R₁₈ are independentlyselected from the group consisting of a substituted or unsubstitutedaminoalkyl, a substituted or unsubstituted aminoalkyloxy, a substitutedor unsubstituted alkylcarboxyalkyl, a substituted or unsubstitutedalkylaminoalkylamino, a substituted or unsubstitutedalkylaminoalkylaminoalkylamino, a substituted or unsubstitutedaminoalkylcarboxy, a substituted or unsubstituted arylaminoalkyl, asubstituted or unsubstituted aminoalkyloxyaminoalkylaminocarbonyl, asubstituted or unsubstituted aminoalkylaminocarbonyl, a substituted orunsubstituted aminoalkylcarboxyamido, a quaternaryammoniumalkylcarboxy,a substituted or unsubstituted di(alkyl)aminoalkyl, H₂N—HC(Q₅)-C(O)—O—,H₂N—HC(Q₅)-C(O)—N(H)—, azidoalkyloxy, cyanoalkyloxy,P.G.-HN—HC(Q₅)-C(O)—O—, a substituted or unsubstitutedguanidinoalkyloxy, and a substituted or unsubstitutedguanidinoalkylcarboxy.
 21. The method of claim 20, wherein m, n, and p,are each 1 and q is
 0. 22. The method of claim 20, wherein R₁ throughR₄, R₆, R₇, R₁₁, R₁₂, R₁₅, R₁₆, and R₁₈ are independently selected fromthe group consisting of hydrogen, hydroxyl, an unsubstituted (C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈) hydroxyalkyl, unsubstituted (C₁-C₁₈)alkyloxy-(C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈) alkylamino-(C₁-C₁₈) alkyl, unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, (C₁-C₁₈) alkylamino-(C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted (C₁-C₁₈) aminoalkyl, anunsubstituted aryl, an unsubstituted arylamino-(C₁-C₁₈) alkyl, oxo, anunsubstituted (C₁-C₁₈) aminoalkyloxy, an unsubstituted (C₁-C₁₈)aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxy, an unsubstituted (C₁-C₁₈) aminoalkylaminocarbonyl, anunsubstituted (C₁-C₁₈) aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈alkyl)aminoalkyl, unsubstituted (C₁-C₁₈) guanidinoalkyloxy,unsubstituted (C₁-C₁₈) quaternaryammoniumalkylcarboxy, and unsubstituted(C₁-C₁₈) guanidinoalkyl carboxy; R₅, R₈, R₉, R₁₀, R₁₃, R₁₄ and R₁₇ areindependently deleted when one of rings A, B, C, or D is unsaturated soas to complete the valency of the carbon atom at that site, or R₅, R₈,R₉, R₁₀, R₁₃, and R₁₄ are independently selected from the groupconsisting of hydrogen, hydroxyl, an unsubstituted (C₁-C₁₈) alkyl,unsubstituted (C₁-C₁₈) hydroxyalkyl, unsubstituted (C₁-C₁₈)alkyloxy-(C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈) alkylamino-(C₁-C₁₈)alkyl, (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted(C₁-C₁₈) aminoalkyl, an unsubstituted aryl, an unsubstitutedarylamino-(C₁-C₁₈) alkyl, oxo, an unsubstituted (C₁-C₁₈) aminoalkyloxy,an unsubstituted (C₁-C₁₈) aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted(C₁-C₁₈) aminoalkylcarboxy, an unsubstituted (C₁-C₁₈)aminoalkylaminocarbonyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈ alkyl)aminoalkyl,unsubstituted (C₁-C₁₈) guanidinoalkyloxy, unsubstituted (C₁-C₁₈)quaternaryammoniumalkylcarboxy, and unsubstituted (C₁-C₁₈)guanidinoalkyl carboxy; provided that at least two or three of R₁₋₄, R₆,R₇, R₁₁, R₁₂, R₁₅, R₁₆, R₁₇, and R₁₈ are independently selected from thegroup consisting of hydrogen, hydroxyl, an unsubstituted (C₁-C₁₈) alkyl,unsubstituted (C₁-C₁₈) hydroxyalkyl, unsubstituted (C₁-C₁₈)alkyloxy-(C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈) alkylamino-(C₁-C₁₈)alkyl, unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted(C₁-C₁₈) aminoalkyl, an unsubstituted aryl, an unsubstitutedarylamino-(C₁-C₁₈) alkyl, oxo, an unsubstituted (C₁-C₁₈) aminoalkyloxy,an unsubstituted (C₁-C₁₈) aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted(C₁-C₁₈) aminoalkylcarboxy, an unsubstituted (C₁-C₁₈)aminoalkylaminocarbonyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈ alkyl)aminoalkyl,unsubstituted (C₁-C₁₈) guanidinoalkyloxy, unsubstituted (C₁-C₁₈)quaternaryammoniumalkylcarboxy, and unsubstituted (C₁-C₁₈)guanidinoalkyl carboxy.
 23. The method of claim 1, wherein the CSA, or apharmaceutically acceptable salt thereof, is selected from the compoundof Formula (II):


24. The method of claim 23, wherein rings A, B, C, and D areindependently saturated.
 25. The method of claim 23, wherein R₃, R₇,R₁₂, and R₁₈ are independently selected from the group consisting ofhydrogen, an unsubstituted (C₁-C₁₈) alkyl, unsubstituted (C₁-C₁₈)hydroxyalkyl, unsubstituted (C₁-C₁₈) alkyloxy-(C₁-C₁₈) alkyl,unsubstituted (C₁-C₁₈) alkylcarboxy-(C₁-C₁₈) alkyl, unsubstituted(C₁-C₁₈) alkylamino-(C₁-C₁₈)alkyl, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino, unsubstituted (C₁-C₁₈)alkylamino-(C₁-C₁₈) alkylamino-(C₁-C₁₈) alkylamino, an unsubstituted(C₁-C₁₈) aminoalkyl, an unsubstituted arylamino-(C₁-C₁₈) alkyl, anunsubstituted (C₁-C₁₈) aminoalkyloxy, an unsubstituted (C₁-C₁₈)aminoalkyloxy-(C₁-C₁₈) alkyl, an unsubstituted (C₁-C₁₈)aminoalkylcarboxy, an unsubstituted (C₁-C₁₈) aminoalkylaminocarbonyl, anunsubstituted (C₁-C₁₈) aminoalkylcarboxamido, an unsubstituted di(C₁-C₁₈alkyl) aminoalkyl, unsubstituted (C₁-C₁₈) guanidinoalkyloxy,unsubstituted (C₁-C₁₈) quaternaryammoniumalkylcarboxy, and unsubstituted(C₁-C₁₈) guanidinoalkyl carboxy; and R₁, R₂, R₄, R₅, R₆, R₈, R₉, R₁₀,R₁₁, R₁₃, R₁₄, R₁₅, R₁₆, and R₁₇ are independently selected from thegroup consisting of hydrogen and unsubstituted (C₁-C₆) alkyl.
 26. Themethod of claim 25, wherein R₁, R₂, R₄, R₅, R₆, R₈, R₁₀, R₁₁, R₁₄, R₁₆,and R₁₇ are each hydrogen; and R₉ and R₁₃ are each methyl.
 27. Themethod of claim 25, wherein R₃, R₇, R₁₂, and R₁₈ are independentlyselected from the group consisting of aminoalkyloxy; aminoalkylcarboxy;alkylaminoalkyl; alkoxycarbonylalkyl; alkylcarbonylalkyl;di(alkyl)aminoalkyl; alkoxycarbonylalkyl; and alkylcarboxyalkyl.
 28. Themethod of claim 25, wherein R₃, R₇, and R₁₂ are independently selectedfrom the group consisting of aminoalkyloxy and aminoalkylcarboxy; andR₁₈ is selected from the group consisting of alkylaminoalkyl;alkoxycarbonylalkyl; alkylcarbonyloxyalkyl; di(alkyl)aminoalkyl;alkylaminoalkyl; alkyoxycarbonylalkyl; and alkylcarboxyalkyl.
 29. Themethod of claim 25, wherein R₃, R₇, and R₁₂ are the same.
 30. The methodof claim 25, wherein R₃, R₇, and R₁₂ are aminoalkyloxy.
 31. The methodof claim 25, wherein R₁₈ is alkylaminoalkyl.
 32. The method of claim 25,wherein R₁₈ is alkoxycarbonylalkyl.
 33. The method of claim 25, whereinR₁₈ is di(alkyl)aminoalkyl.
 34. The method of claim 25, wherein R₁₈ isalkylcarboxyalkyl.
 35. The method of claim 25, wherein R₃, R₇, and R₁₂are aminoalkylcarboxy.
 36. The method of claim 25, wherein R₁₈ isalkylaminoalkyl.
 37. The method of claim 24, wherein R₁₈ isalkoxycarbonylalkyl.
 38. The method of claim 25, wherein R₁₈ isdi(alkyl)aminoalkyl.
 39. The method of claim 25, wherein R₁₈ isalkylcarboxyalkyl.
 40. The method of claim 25, wherein R₃, R₇, R₁₂, andR₁₈ are independently selected from the group consisting ofamino-C₃-alkyloxy; amino-C₃-alkyl-carboxy; C₈-alkylamino-C₅-alkyl;C₈-alkoxy-carbonyl-C₄-alkyl; C₁₀-alkoxy-carbonyl-C₄-alkyl;C₈-alkyl-carbonyl-C₄-alkyl; di-(C₅-alkyl)amino-C₅-alkyl;C₁₃-alkylamino-C₅-alkyl; C₆-alkoxy-carbonyl-C₄-alkyl;C₆-alkyl-carboxy-C₄-alkyl; and C₁₆-alkylamino-C₅-alkyl.
 41. The methodof claim 1, wherein the CSA, or a pharmaceutically acceptable saltthereof, is selected from the compound of Formula (III):


42. The method of claim 41, wherein the CSA, or a pharmaceuticallyacceptable salt thereof, is selected from the group consisting of:


43. The method of claim 42, wherein the compound of Formula (III), or apharmaceutically acceptable salt thereof, is


44. The method of claim 42, wherein the compound of Formula (III), or apharmaceutically acceptable salt thereof, is


45. The method of claim 42, wherein the compound of Formula (III), or apharmaceutically acceptable salt thereof, is


46. The method of claim 42, wherein the compound of Formula (III), or apharmaceutically acceptable salt thereof, is


47. A CSA composition, comprising at least one CSA and one or morepoloxymers.
 48. The CSA composition of claim 47, further comprisingalbumin.
 49. The CSA composition of claim 47, wherein the compositioncontains less than about 20% by weight of CSA; and between about 10% toabout 40% by weight of one or more poloxymer or between about 20% toabout 30% by weight of one or more poloxymers.
 50. The CSA compositionof claim 47, wherein the ratio of the one or more poloxamers to CSA isbetween about 30 to 1 to about 3 to
 1. 51. The CSA composition of claim47, wherein the one or more poloxamers has a molecular weight of about3600 g/mol for the central hydrophobic chain of polyoxypropylene and hasabout 70% polyoxyethylene content.